Temple Knights Tai Chi & Chi Kung Retreat
Registration Form

 

Name:
____________________________________________

Address:

____________________________________________

____________________________________________

____________________________________________

___________________ Postal Code: _____________

Telephone #:
_____________________________

E-mail:
_____________________________

Birthdate:

_____________________________
mm/dd/yyyy

General Health:

_______________________________________________________

_______________________________________________________

_______________________________________________________

Special Diet Requirements:

_______________________________________________________

_______________________________________________________

_______________________________________________________

Previous Martial Arts Experience:

_______________________________________________________

_______________________________________________________

_______________________________________________________

What do you hope to gain from this camp?

_______________________________________________________

_______________________________________________________

_______________________________________________________
WAIVER:

By signing this registration form I certify that the above information i
s correct. As a participant I acknowledge that the Temple Knights and their
representatives shall in no form be liable or responsible for injury or
bodily harm occurring to me during classes and that such risks shall be borne
by myself voluntarily.
  _______________________________________________

 
SIGNATURE, or Signature of Guardian

 

DATE: _______________
   

Payment by Cash, Cheque (payable to Temple Knights) or Visa.
P.O. Box 336, Bracebridge, On., P1L 1T7
Ph. Muskoka (705) 767-1177 
Fax: (705) 767-1165 
tknights@muskoka.com