dan inosanto - Nino Pilla International Academy of Martial Arts

REGISTRATION FORM
ADELAIDE
6-7 DEC 2012
(08) 8212 5606
MELBOURNE
8-9 DEC 2012
0415 131 812
BRISBANE:
Name
PLEASE TICK:
BRISBANE WORKSHOP 1 Thursday, 29 Nov 2012
BRISBANE WORKSHOP 2 Friday, 30 Nov 2012
BRISBANE SEMINAR 1 Saturday, 1 Dec 2012
BRISBANE SEMINAR 2 Sunday, 2 Dec 2012
ADELAIDE WORKSHOP Thursday, 6 Dec 2012
ADELAIDE SEMINAR Friday, 7 Dec 2012
SEMINAR DETAILS
BRISBANE
29 NOV - 4 DEC
(07) 3393 9329
Silat (TBC) Workshop
Thurs, 29 Nov 2012
6pm to 8pm
Muay Thai Workshop
Fri, 30 Nov 2012
5:30pm to 7:30pm
Jun Fan / Kali / JKD / Silat
Sat, 1 Dec 2012
9am to 12pm Jun Fan / Kali / JKD / Silat
Sun, 2 Dec 2012
9am to 12pm
Progressive Martial Arts Academy International
Unit 2/95 Ingleston Road, Wakerley, QLD, 4154
Contact: Cookie and Q Vassiliou
T: (07) 3393 9329 www.progressivemartialarts.com.au
MELBOURNE SEMINAR 1 Saturday, 8 Dec 2012
ADELAIDE:
MELBOURNE SEMINAR 2 Sunday, 9 Dec 2012
Muay Thai Workshop
Thu, 6 Dec 2012
6:30pm to 8:30pm
IIMAIA INSTRUCTORS COURSE
1 - 4 December 2012 (by invitation only)
WORKSHOP / SEMINAR COSTS:
1 Day: $110* / $130
2 Days: $200* / $250
3 Days: $300* / $330
4 Days: $400* / $440
*Pre-paid ticket prices only valid if payment received
before Thursday, 1 November 2012.
Please return this application form and payment
to your seminar representative:
In Person: By Cash, Cheque or Money Order
Mail: Cheque or Money Order written out
to V. Vassiliou and mail to:
PO Box 9106, Wynnum Plaza, Wynnum QLD 4178
Visa / Mastercard: By Phone (07) 3393 9329
or Online at www.progressivemartialarts.com.au
Electronic Funds Transfer (EFT):
Account Name: Progressive Martial Arts
BSB: 064 133 Account: 1027 4248
Please include your Name and State as reference
Jun Fan / Kali / JKD / Silat
Fri, 7 Dec 2012
6:30pm to 9:30pm
Nino Pilla International Academy of Martial Arts
Basement, 118 King William Street, Adelaide SA 5000
Contact: Nino Pilla
T: (08) 8212 5606 www.ninopilla.com
MELBOURNE:
Jun Fan / Kali / JKD / Silat Sat, 8 Dec 2012
10:30am to 1:30pm
Jun Fan / Kali / JKD / Silat
Sun, 9 Dec 2012
10:30am to 1:30pm
Progressive Martial Arts Academy, Melbourne
3 Olive Street Malvern East Victoria 3145
Contact: Bruce McCulloch
T: 0405 131 812 www.progressivemaam.com.au
TRAINING EQUIPMENT
Focus mitts, bag gloves, kali sticks, training knife.
Training equipment and merchandise will be available
to purchase on the day and can be pre-ordered.
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TERMS & CONDITIONS
PLEASE READ THE FOLLOWING CAREFULLY
1. I, the undersigned acknowledge that I have applied to voluntarily participate in the Dan Inosanto Seminar.
2. I am aware that participating in, learning, training and observing the practice of Jun Fan Gung Fu /
Jeet Kuen / Maphilindo Silat / Filipino Martial Arts / Muay Thai and/or any other martial arts form that
may be demonstrated, practiced or taught during the Dan Inosanto Seminar may be a dangerous
undertaking and in undertaking any such activities I do so at my own risk.
3. I am also aware that it is a condition of admission to the Dan Inosanto Seminar, that the Nino
Pilla International Academy of Martial Arts Pty Ltd, the Progressive Martial Arts Academy, their
directors, instructors, members, servants or agents together with the Inosanto Academy, its
directors, servants or agents and the Dan Inosanto Seminar Sponsors are absolved from any liability
howsoever arising from injury or damage howsoever caused (whether fatal or otherwise) arising
out of participating in the Dan Inosanto Seminar, including learning, training and observing the
practice of Jun Fan Gung Fu / Jeet Kuen / Maphilindo Silat / Filipino Martial Arts / Muay Thai and/
or any other martial arts form that may be demonstrated, practiced, taught or observed during the
Dan Inosanto Seminar, or in any way whatsoever due to any negligent act, breach of duty, default
and/or omission on the part of the Nino Pilla International Academy of Martial Arts Pty Ltd, the
Progressive Martial Arts Academy, their directors, instructors, members, servants or agents, or on
the part of the Inosanto Academy, its directors, instructors, members, servants or agents or on
behalf of the Dan Inosanto Seminar Sponsors.
4. I am also aware that any person practicing, learning, training or observing Jun Fan Gung Fu / Jeet
Kuen / Maphilindo Silat / Filipino Martial Arts / Muay Thai and/or participating, learning, training or
observing any other form or martial arts or any activity whatsoever carried out during the Dan Inosanto
Seminar are only allowed to do so on the distinct understanding that they do so at their own risk.
5. I acknowledge and am aware that participation in the Dan Inosanto Seminar may involve extremely
strenuous physical activity and to consult my doctor if I have any physical condition or impairment
that may prevent me from fully participating in the Dan Inosanto Seminar before commencing and
undertaking such activity. I hereby represent that, to the best of my knowledge, I am in good physical
health and condition, sufficient to undertake all activities and practices during the Dan Inosanto Seminar.
6. I understand that during the Dan Inosanto Seminar no photographs may be taken, and audio and
video recording is strictly prohibited without prior express written consent of the Dan Inosanto
Seminar Sponsors or Inosanto Academy. In addition, should I obtain prior written permission to take
photographs; I agree that such photographs shall only be used by me and by no one else, for my
own personal use and not for commercial gain or for any other purpose.
I,
of
(Your name)
(Address)
An opportunity to meet and train with Guro Dan Inosanto.
A true pioneer of the Mixed Martial Arts and one of the
most renown and sought after instructors in the business.
Whether you are a beginner or a master in any of the
martial arts, The Inosanto Tour will be sure to inspire.
Arts covered include: Jeet Kune Do, Filipino Martial Arts,
Silat, Muay Thai and many more.
(Home Phone)
(Work Phone)
(Postcode)
(Mobile)
(Email)
(Age)
DO HEREBY ACKNOWLEDGE that of my own free will and desire I submit my application to participate
in the Dan Inosanto Seminar for instruction and training in martial arts (Jun Fan Gung Fu/Jeet Kuen/
Maphilindo Silat/Filipino Martial Arts) activities mentioned above and that I have read and understood the
warning in paragraph 5 above.
Signed by the said
(Signature or that of a parent/guardian if under 18years))
In the presence of
(Name of witness)
BROUGHT TO YOU BY PROGRESSIVE MARTIAL ARTS ACADEMY INTERNATIONAL AND NINO PILLA INTERNATIONAL ACADEMY OF MARTIAL ARTS
(Signature of witness)