APPLICATION FOR OKAZAKI RESTORATIVE MASSAGE COURSE
(Download Registration Form)

PLEASE CHECK ONE:
___ Module 1, Massage Technician
___ Module 2, Massage Practitioner
___ Module 3, Massage Therapist

NAME: ___________________ _________________ ___________________________

DATE OF BIRTH: _____/ _____ / _____ SOC. SEC. NO.: _______ - ____ - _________

ADDRESS: ________________________________________________________________

_________________________________________________________________________

HOME PH: ( _____ ) ___________________ WORK PH: ( _____ ) __________________

AJJF JUJITSU RANK: _______________ E-MAIL ADDRESS _____________________

SENSEI: _________________________ SCHOOL: _______________________________

AJJF #: ______________________________ EXPIRATION DATE: _________________

If you are not an AJJF member, or your AJJF membership expires before the completion of the massage program, you will be required to renew membership. Please request an AJJF membership application from your sensei, AJJF Central Office, of the Massage Program Administrator. Return you application and fee to the Massage Program Administrator and it will be processed and forwarded to Central Office.

CHECK HERE IF YOU NEED AN AJJF APPLICATION FORM SENT TO YOU: _____

HAVE YOU HAD OTHER MASSAGE TRAINING? yes _______ no _______

STYLE: ___________________________ SCHOOL: _____________________________

ARE YOU CERTIFIED IN MASSAGE? yes _______ no ________

DO YOU PRACTICE MASSAGE PROFESSIONALLY? yes ___ no ___ How long? ____

DO YOU PLAN TO PRACTICE MASSAGE PROFESSIONALLY? yes ____ no ____

My signature below affirms my intention to participate in this program and complete all requirements for certification. I have never been convicted of, nor pled guilty to, any violent or sex-related crime. I am not currently being treated for, nor am diagnosed as having, any condition of psychological deformity or disease. I am not currently infected with any serious communicable disease. I will inform the representatives of this Institute in the event that any of these conditions change during the course of instruction.

SIGNATURE: _____________________________________ DATE: _____________

To the best of my knowledge, this person is sincerely interested in pursuing excellence in the practice and understanding of the Okazaki Restorative Massage, and has the character to uphold the highest ethical and moral standards in the practice of massage. I hereby recommend that this individual be accepted into the AJJF National Massage Certification Program.

_________________________________________________ DATE: ______________
Signature of AJJF Jujitsu Black Belt

Mail completed form with a $150.00 refundable registration fee (payable to Fudochi Dojo) to:

Prof. Robert Hudson
The DZRSI of Southern California
1780 West Saddle Butte St.
Apache Junction, AZ 85220

The DanZanRyu Seifukujitsu Institute is a program of The American Judo and Jujitsu Federation as part of its National Massage Certification Program

The DanZanRyu Seifukujitsu Institute is a program of
The American Judo and Jujitsu Federation as part of its
National Massage Certification Program DZRSI of SOUTHERN CALIFORNIA