Clone of Be Your Own Bodyguard - REACT Registration Form

RON BALICKI SEMINAR

SATURDAY, AUGUST 1: 10AM-2:15PM
The Northshore Academy of Martial Arts is honored to host great friend and mentor Guro Ron Balicki…for an outstanding event on Saturday, August 1st! Train with the best in Kali, Silat & Weapons… This is an opportunity to meet one of the greatest living legends!
INSTRUCTORS:
GURO RON BALICKI

WHERE:
Northshore Academy of Martial Arts
281 Peterson Road | Libertyville, IL 60048
847.573.1672 |  nsama@nsama.com

WHEN:
SATURDAY: AUG 1 | 10:00AM – 2:15PM
WHAT YOU WILL LEARN:

• KALI
• SILAT
• WEAPONS

EARLY BIRD:
$139.00

AFTER EARLY BIRD:
$159.00 - ENDS JULY 20
SEMINAR ATTENDEE(S):
NUMBER OF ATTENDEES

1ST ATTENDEE: FIRST & LAST NAME
1ST ATTENDEE: EMAIL
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1ST ATTENDEE: PHONE NUMBER
Please enter a valid phone number.Format: (000) 000-0000.
1ST ATTENDEE: ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

2ND ATTENDEE: FIRST & LAST NAME
2ND ATTENDEE: EMAIL
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2ND ATTENDEE: PHONE NUMBER
Please enter a valid phone number.Format: (000) 000-0000.
2ND ATTENDEE: ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

3RD ATTENDEE - FIRST & LAST NAME
3RD ATTENDEE: EMAIL
example@example.com
3RD ATTENDEE: PHONE NUMBER
Please enter a valid phone number.Format: (000) 000-0000.
3RD ATTENDEE: ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
QUESTIONS:
QUESTIONS/COMMENTS
WAIVER:

In consideration of your acceptance of this form, I, for myself, my heirs, executors, administrators, and assigns, hereby waive, release, and discharge any and all rights and claims for damages, known or unknown, that I may have against The Northshore Academy of Martial Arts and Ron Balicki (MARS: Martial Arts Research Systems), their employees, members, or instructors, including but not limited to our Annual Pagtitipon Filipino Martial Arts Seminar, for any injuries arising from my participation in this event.

I acknowledge and accept the inherent risks associated with the Saturday, August 1st Ron Balicki Seminar, martial arts, self-defense, weights, exercise, and fitness programs, and I voluntarily assume these risks as incidental to participation. I agree to assume and pay for my own medical and emergency expenses in the event of accident, illness, or other incapacity, regardless of whether I have authorized such expenses.

I certify that I am medically and physically fit to participate in this Martial Arts Seminar. Additionally, I consent to The Northshore Academy of Martial Arts and Combat Warrior Academy, their owners, instructors, employees, and other Adult students to administer minor emergency first aid and/or advice as necessary, releasing them from any claims related to such treatment.

I understand and agree that all dues and payments for seminars are non-refundable and non-transferable. Furthermore, I grant The Northshore Academy of Martial Arts and Ron Balicki (MARS: Martial Arts Research Systems) permission to use any photos taken of me for publicity purposes.
1ST ATTENDEE SIGNATURE

First NameLast Name
Waiver Agreement Signature
Today's Date

MonthDayYear
Date

2ND ATTENDEE SIGNATURE

First NameLast Name
Waiver Agreement Signature
Today's Date

MonthDayYear
Date

3RD ATTENDEE SIGNATURE

First NameLast Name
Waiver Agreement Signature
Today's Date

MonthDayYear
Date
PURCHASE:
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RON BALICKI SEMINAR - SAT AUG 1 PASS
Saturday, August 1: 10am-2:15pm

$139.00 Quantity
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RON BALICKI SEMINAR

Debit • Credit • Paypal*

Payment Methods

Debit • Credit • Paypal