Registration Application

Ki Gong South Clinic - Austin, Texas

Sponsored by Mindful Movements of Ki Gong

April 8, 2017

8:30am to 3:30pm


Name _________________________________________________________________________________


Address _______________________________________________________________________________


City _________________ State ____________ Zip ____________ Country _________________________


Phone ______________________ E-mail ___________________________________________________


Light lunch will be provided. Water will be available. Feel free to bring your own lunch items.

Any special needs? Please explain: ___________________________________________________


****We prefer you to wear the official World Ki Gong Club uniform while participating in the Clinic.

In order to place the request, all Uniform request must be paid for by the Mar 17, 2017 deadline.

If application submitted after Mar 17, 2017 plan to wear a plain white shirt and black pants.


Are you a World Ki Gong Club Member? _____ Yes.

If you would like to join World Ki Gong Club, applications will be available at the Austin clinic.



Application Submitted by: 3/17/2017 until 4/3/2017 (final)

Ki Gong Clinic




Ki Gong Shirt **




Ki Gong Pants **




** T-shirts/pants cannot be ordered after the 1st deadline


T-shirt Adult Sizes (S M L XL XXL)

Rank Color_________ White (I,II) Yellow (III), Blue (IV, V), Red (VI)

Pants Size (1 2 3 4 5 6)


Total Amount Due $ __________

Make check payable to: Ek Creations Studio

13466 Gent Drive

Austin, Texas 78729


Hotel accommodations at “Ki Gong South” rates available till Mar 17 for $112 King, $122 Queens

Call Fairfield Inn & Suites, 13087 US HWY 183 N, Austin TX, 78750 Phone: 512-258-410


I understand all requirements of my clinic participation and agree to abide by all rules. By registering for this clinic

I understand that the practice of Ki Gong requires time, patience and hard work. I expect to learn healthy application

of time tested principles and do not expect diagnosis or cure of any disease process. I assume all risk. I hold

harmless all instructors, agents, principles or members of the World Ki Gong Club and the WTSDA.


Signature ________________________________________ Date _____________