ATERU WORLDWIDE ASSOCIATION

ATERU WORLDWIDE ASSOCIATION
900 Bright Road Findlay, Ohio USA 45840 (phone 1.419.422.9262)

INDIVIDUAL ASSOCIATE MEMBERSHIP FORM

($30 US Money Order, add $10.00 US if shipping outside of USA)

Full Name:___________________________________ Date:______ Rank:_________

Address:_________________________________ Phone:_______________________

State or Province:__________________________ Postal Code:__________________

Country:_______________________ Email:_______________________________

Amount paid today:_________________ (All funds to be paid in US dollars)

In consideration of my acceptance into membership, I agree to release, hold harmless and indemnify the Ateru Worldwide Association, including but not limited to, officers, participating members and instructors, all clubs, organizations, and firms of any and all liability for bodily injuries, disease, or ill health, or the aggravation of such, disease, all claims, demands, cost, losses, and expenses, which I, my heirs and personal representatives may have arising out of, or caused in any way by, or having any connection with my participation in school activities, training, contests, and practice, and/or the use of any and/or all facilities and materials owned, leased, or in the care or use, custody, or control of any of the above listed, including traveling to and from martial arts activities. If accepted I agree to abide by the association’s rules, regulations and constitution and to contribute to the goals of the AWA. Please Make money order Payable to:

Ateru Worldwide Association

Signed___________________________________Date_________________________

Co-signed________________________________ Date_________________________ (if under 21 years of age)

Instructor/Officer__________________________Date__________________________

------------------------------------------------------------------------------------------------------------For AWA Headquarters Use Only------------------------------------------------------

Date Recorded________________ AWA Patch:_______ AWA Card:_________

Rank Diploma:_______ Teaching Credentials:_______ RenewalDate:_________