United States Martial Arts Hall of Fame
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UNITED STATES MARTIAL ARTS HALL OF FAME AND NATIONAL TRAINING CAMP Name_______________________________________________________________________________ Address___________________________________City__________________State_________________ Zip_____________Phone_______________________ Secondary Phone__________________________ Email_____________________________ Date of Birth________________ Age____________________ Highest Current Rank__________________________ Style____________________________________ Instructor_________________________ Association_________________________________________ Your School Name_____________________________________________________________________ Address ____________________________________________State ____________ Zip_____________ Defensive Tactics Instructor Course Participants (Please provide the following additional information) Are you a sworn officer? Y N If Yes, which department _____________________________________ Rank____________________ Occupation / Position________________________________________ Are you active duty military? Y N Are you reserve military Y N Branch _____________ Current duty station______________________________ Occupation / Position __________________ Previous defensive tactics training ________________________________________________________ Certification: You will be certified as a Defensive Tactics Instructor through Krav Maga Tactical Training Options Certification is good for two years and must be renewed in order to be recognized by Krav Maga TTO. Registration Fees Before July 15 After July 15 Traditional Training Camp $125 $150 MMA Training Camp $125 $150 DT Instructors Course $500 $500 Hall of Fame Banquet & Awards Ceremony $60 $60 Waiver I, the below-signed individual, voluntarily submit my application for training with the International Martial Arts Council of America (IMAC), United States Martial Arts Hall Of Fame, Krav Maga Tactical Training Options and hereby declare that, to the best of my knowledge and ability, the information on this application is true and factual. Section I. I, the undersigned, request the privilege of admission to the course organized by The International Martial Arts Council, and given at the above mentioned place and time. I understand that the classes taught in this seminar are martial arts oriented involving strenuous exercise and physical contact. I understand that the martial arts and related defensive tactics are inherently dangerous and I could face severe injury or death from participation in this event. I further understand that neither The International Martial Arts Council, nor the organizers of this seminar offer any insurance or guarantees of any sort, nor subscribe to any insurance against injuries to the course participants or damage to their property. In consideration of the privilege of being admitted to participate in the course, of receiving the provided instruction and of using the host organization’s installations for the duration of the seminar, I hereby declare that I will personally assume all responsibility concerning any injury that I may incur or that may be inflicted on me by others during the course, be it on or off the premises, before, after, during or between sessions. I hereby hold immune and release, The International Martial Arts Council, Marty Cale, its directors, employees, agents and representatives from all responsibility, accountability, and any reparations concerning personal injuries, lawsuits, damages, losses of any nature whatsoever, in law and equity, relative to the activities mentioned above. I hereby agree and engage, in the name of my heirs and beneficiaries, never to pursue, legally or in equity The International Martial Arts Council, Marty Cale, employees, agents or representatives in relation to such injuries, lawsuits, damages, responsibilities, accountabilities, reparations or losses. Your signature below also shall act as an image release allowing photos taken to be used in promotional material. Section II. Sworn Officers – read and initial All techniques, principles and philosophies presented in this course are designed to be used as a supplement to department based defensive tactics training. As a professional officer you MUST follow your department policy regarding use of force and permissible techniques. At no time should you violate city, county, or state policy by using techniques not endorsed by same. The International Martial Arts Council, Marty Cale, its/their directors, employees, agents and representatives will not be held responsible for violation of any policy. Initial________ TO ATTEST TO THIS, I have signed this document and declare that I have read it and understand it. Signature ___________________________________ Date ____________________ Signature of Parent or Guardian____________________________ Date________________ (If participant is under 18 years of age) If Paying by Credit Card [ ] VISA/Mastercard Name on Credit Card: _______________________________ [ ] Discover Credit Card # ______________________________________ [ ] American Express Expiration Date: ____ / ____ CSV # __________________ CSV Number is the 3-digit number on the back of your VISA/Mastercard or Discover Card, or the 4 digit number on the front of your AMEX Amount Authorized: $_____________ Authorized Signature: _______________________________ Date Signed: ___________________ Printed Name: _____________________________________
