HOLD HARMLESS RELEASE FORM

Jackson, MI 49202-1948

Lee Norton
2313 W. Argyle St.
(Please PRINT all information)
Norton’s Isshin-Ryu
Name: _____________________________________ Karate School of Jackson
Age: ____ Address: __________________________ Is proud to sponsor a martial arts seminar by
City: ____________________________State: _____ Sensei John Kerker,
Zip: ___________ Phone: (____)________________ Senior student of Sensei Sherman Harrill.
E-mail: ____________________________________
My instructor: _______________________________
School where I train: _________________________
__________________________________________

I, the undersigned, register myself for a

seminar/workshop in martial arts techniques, which is
sponsored by Norton’s Isshin-Ryu Karate School, and
is taught by Mr. John Kerker of Kerker’s Isshin-Ryu
Karate School, Inc., and held at Norton’s Isshin-Ryu
Karate School of Jackson, Michigan.
I recognize the possibility of injury inherent in this
activity, and I further understand that said risk may arise
from, but is not limited to, the instruction, explanation, and or
practice and training in the subject matter presented at this
seminar. I realize that all risk or injury or loss of any kind
assumed by me and I will hold harmless Mr. John Kerker,
Kerker’s Isshin-Ryu Karate School, Inc., The Holiday Inn of
Jackson, Norton’s Isshin-Ryu Karate School, their owner, Mr. Kerker has been the Carson Dojo
officials, instructors, other seminar participants, employees of Sempai and floor instructor for many years.
said organizations, and their agents, for any and all losses and He has traveled the country assisting Sensei
or injuries sustained by me as the result of this seminar.
Harrill with his seminars since he was a
I am in good general health and physical condition and
assume costs of any and all losses and or injuries myself. I green belt. Anyone who has spent time with
agree to conduct myself courteously and obey the rules set Mr. Kerker in the dojo or at one of Mr.
forth for training at this seminar, based on Oriental traditions Kerker’s seminars knows that basics, kata
of courtesy and common sense. and the application of technique along with
Tatsuo Shimabuku kumite techniques are
the things that will be worked on.
Signature of enrollee
Mr. Kerker was entrusted by Sensei Harrill
Parent or guardian if under 19 years
with the students of the Carson dojo, where
he continues to this day teaching, as he was
Date: _________________ himself taught.
 INSTRUCTOR: Local Hotels:
Post Seminar Dinner
SENSEI JOHN KERKER with Sensei Kerker,
Fairfield Inn, this is the hotel where Sensei
Kerker will be staying. (2395 Shirley Dr., June 11, 2011.
DATE & TIME: 517-784-7877. Located at exit 138 on I-94 at
SATURDAY JUNE 11, 2011 US-127.). After the seminar we will be getting
together for dinner and conversation at a
9:00 A.M. TO 4:00 P.M. Baymont Inns, 2035 Holiday Inn Drive. local restaurant. We will take a head count
517-789-6000 at the start of the seminar of those persons
LOCATION: indicating an interest in joining us.
NORTON’S ISSHIN-RYU Super 8 Motel, 2001 Shirley Dr.
KARATE SCHOOL 517-788-8780 (Exit 138 on I-94 at US-127) The dinner check will be your
137-1/2 E. MICHIGAN AVE. responsibility and is NOT included in the
JACKSON, MICHIGAN Motel 6, 830 Royal, 517-789-7186 seminar fee.
(Exit 138 on I-94 at US-127)
(No locker or shower facilities)
While we do not plan to stop for a “lunch hour”, Hampton Inn, 2225 Shirley Dr.
occasional 15-minute breaks are planned during 517-789-5151 (Exit 138 on I-94 at US-127)
which you may eat or drink any snack you bring
along. A municipal parking lot is behind the dojo Country Hearth Inn, 1111 Boardman.
on Courtland St. 517-783-6404 (Exit 138 on I-94 at US-127)

Comfort Inn, 2435 Shirley Dr.

FEES: 517-768-0088 (Exit 138 on I-94 at US-127,
$60.00 if pre-registered by May 31, 2011 go figure)
$70.00 cash (no checks) at the door
Registration: Saturday, 8:30 – 9:00 a.m.

Please mail your completed

Hold Harmless Release Form with
Check Payable to:

LEE NORTON
2313 W. ARGYLE ST.
JACKSON, MI 49202-1948
1-517-784-6030