MARTINEZ ACADEMY OF ARMS

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ANTHONY DE LONGIS WORKSHOP

Registration Form

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Name:____________________________________________________________________

Address:_________________________________________________________________

City:______________________ State:_____ Zip:________  Country: __________

Gender: [ ]Male [ ]Female   Years Fencing: ______

Stage Combat Experience: ________________________________________________

Home Phone: (______)______-______

Work Phone: (______)______-______

Fax: (______)______-______

E-mail: ________________________________________

Fees

Pre-Registration for both workshops, $175.00
Pre-Registration for sword workshop alone, $100.00
Pre-Registration for Whip workshop alone, $100.00

Pre-Registrations must be post marked by January 9, 2004 Full refund if we receive a cancellation notice from the participant by January 2, 2004. After that date no refunds will be made unless the workshop is canceled.

Make Checks or Money orders payable to Ramon Martinez and mail to:

Martinez Academy of Arms
P.O. Box 2484
Secaucus, NJ 07096

Waiver of Liability

Upon participating in this seminar/workshop hosted by Martinez Academy of Arms, I agree to abide by the rules and conditions of the event. I understand and appreciate that participation in fencing and stage combat carries a risk to me of serious injury, including permanent paralysis or death. I knowingly recognize, accept and assume this risk upon participating in this seminar/workshop and release the, Martinez Academy of Arms, Mr. Anthony De Longis, the Union Management Corp. Building, the instructors and the participants, from any liability.

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Fencer/Student Signature                              Date