“RING OF FIRE� REGISTRATION FORM -- Register Online Today Click Here
PRINT THIS FORM TO REGISTER OR: DOWNLOAD THE OFFICIAL RING OF FIRE FLYER COMPLETE WITH REGISTRATION FORM IN ADOBE ACROBAT PDF FORMAT:
ROF FLYER CLICK HERE
SIGN-IN, Waivers, & Registration at the Door from 7:15 a.m. – 7:45 a.m. Saturday & Sunday
All Registration fees are per person. Sorry, No refunds!
SPACE IS LIMITED SO PLEASE REGISTER EARLY!
HOTEL INFORMATION:
A block of specially Discounted rooms in both the Tower and Courtyard, have been reserved UP TO JUNE 1, 2008, for Ring of Fire participants for Friday and Saturday nights. When making reservations you must mention the VDT Academy/Ring of Fire group. GROUP ID: PCIFIRE
THE PALACE STATION HOTEL & CASINO, Hotel Reservations: 1 (800) 634-3101
2411 West Sahara Avenue, LAS VEGAS, NEVADA 89102
FAX this completed form & release waiver w/CREDIT CARD payment to: (562) 920-1827
OR MAIL completed form & release waiver w/payment to:
VDT Communications, Inc.
P.O. Box 1663
Bellflower, CA 90707-1663
Name: ____________________________________________________________________
Address: __________________________________________________________________
City: __________________________________State: _____________ Zip: _____________
Country: _______________________ E-mail Address: ________________________________
Home phone: ________________________ Cell or work phone: ________________________
PLEASE SELECT ONE ONLY:
**MARTIAL ARTS SCHOOL GROUPS: FOR 5 OR MORE STUDENTS REGISTERED AND MAILED OR FAXED IN ALL TOGETHER with payments BY HEAD INSTRUCTOR AT THE SAME TIME, & PRE-REGISTERED FOR ENTIRE RING OF FIRE CAMP BY JUNE 1, 2008; DINNER for One each INCLUDED:
______ $225.00 each - For 5 or More from same school -- 2 DAYS RING OF FIRE CAMP, Dinner for One Included. (Please include name of instructor and school, address and phone)
PRE-REGISTRATION -- RECEIVED OR POSTMARKED UP TO JUNE 1, 2008 (Save $25 !):
______ $250.00 -- 2 DAYS RING OF FIRE CAMP, Dinner for One Included
______ $125.00 -- ONE DAY ONLY, Specify day: ___________________ Dinner NOT included
REGISTRATION RECEIVED OR POSTMARKED AFTER JUNE 1, 2008:
______ $275.00 -- 2 DAYS RING OF FIRE CAMP, Dinner for One Included
______ $150.00 -- ONE DAY ONLY, Specify day: ___________________ Dinner NOT included
SPECTATORS:
______ $125.00 – 2 DAYS RING OF FIRE CAMP, Dinner NOT included
______ $75.00 -- ONE DAY ONLY, Specify day: ___________________ Dinner NOT included
ADDITIONAL DINNER TICKETS: (for one-day participants, spouse, partner, friend(s), family, or spectators)
How many? _________ @ $50.00 each (includes tax & gratuity) = Total amount for additional
dinners: $______________
**TOTAL AMOUNT ENCLOSED: $ _______________________
METHOD OF PAYMENT (circle one) (Please note that all payments by credit card will incur a 3.2% service charge): (Please make payments out to: VDT Communications, Inc. ):
CASH (to be paid in person only), CASHIERS CHECK, MONEY ORDER,
MASTERCARD, VISA, AMEX, DISCOVER
Credit card # _________________________________________ EXP’Y date: ________________
Name as appears on card:
______________________________________________________________________
SIGNATURE of card holder:
______________________________________________________________________
Billing address if different from above: ______________________________________________________________________
______________________________________________________________________
Ring of Fire workshop Release Waiver
I, the undersigned, do fully understand that all participants and instructors that attend the Ring of Fire workshop and participate in the activities do so completely at their own risk. The promoters of this workshop, and the Palace Station Hotel & Casino, in no way take responsibility of the safety of the attendees or participants, while traveling to, while in attendance of, nor in the returning from the workshop. By signing the registration form and this release waiver, that I, the participant (and in the case of minors parents and or legal guardians) do assume all responsibility for any injury or damages that may occur due to ones participation in the Ring of Fire workshop.
Liability and Medical Release
I, the undersigned, do fully understand that while I participate in the Ring of Fire workshop, I do so at my own risk. I do hereby for myself, my heirs, executors, and administrators waive, release, and forever discharge any and all rights and claims for damages which I may have or which hereafter occur to me against the sponsor of the workshop, VDT Academy™, VDT Communications Inc., Victor or Jane deThouars, any of the instructors or other participants, their officers, agents, representatives, successors and or assigns, the the Palace Station Hotel & Casino for any and all liability claims, losses, or damages on account of injury, including death or damage to property, caused or alleged to be caused in whole or part by negligence. I further waive, release, and forever discharge all claims for damages which may be sustained and suffered by me in connection with my association with, or entry in the workshop or which may arise out of my traveling to, participating in, and returning to such workshop. I further agree to waive claims against any persons connected with any injuries I may sustain and likewise assume full responsibility in connection with said workshop.
Release of emergency medical treatment and transportation
I give consent to receive any necessary medical attention should the need arise and will take full responsibility for all payment of medical care and emergency transport charges.
Photo and video release
In signing this document, I also give express permission to have my image photographed or video taped. I release my rights to ownership of said images. I also hereby state that I understand that these images may be used for commercial purposes and that I will not receive compensation or notice of such usage.
SIGNATURE OF PARTICIPANT: (Parent or guardian sign If participant is under age 18)
_______________________________________________________________________
DATE: ____________________________
* Name & Number of person to contact in case of emergency:
______________________________________________________________________________
______________________________________________________________________________
COMPLETE NAME, ADDRESS AND PHONE NUMBER OF PARTICIPANT:
Please Print:
*NAME _____________________________________________________________________
Address _____________________________________________________________________
City __________________________________ State ___________ ZIP _______________
Phone Number(s):
_____________________________________________________________________________