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13TH ANNUAL WKUHOF KARATE TOURNAMENT Chateau Resort & Conference Center Tannersville, Pa. 18372 Sunday, June 12, 2011
NO CHECKS ACCEPTED DAY OF EVENT
REGISTRATION FORM
PERSONAL INFORMATION SCHOOL INFORMATION
Last Name:...............................................Instructor Name:....................................................... |
First Name:....................................................................School Name:....................................... |
Street Address:..........................................Street Address:....................................................... |
City:.............................State:................Zip:...............City:.........................State:..............Zip:......... |
Country:.....................................................................Country:........................................................ |
Telephone:................................................................Telephone:.................................................... |
Age:...............................D.O.B.......................Height:....................................Weight:...................... |
Rank:........................................................Martial Arts Style:....................................................... |
Events of entry: ___________Weapons: ____________Forms:______________Sparring Padded Weapons :_____________ Competition Level: Age:____Beginner:_______Intermediate:______Advanced:________ Black Belt:_______________Executive:___________
Entry fees (non refundable) ______$35.00 ALL EVENTS ( before May 20, 2011
______ $40.00 ALL EVENTS ( after May 20 , 2011) $5.00 Discount WKURS Ratings Members. Member ID Number:____________ Spectator Fees: ________$5.00 ( 12 yrs + up)____________$3.00 ( 5-11yrs.) Make checks or Money Orders payable to: World Karate Union Hall Of Fame 437 Sabol Road Stroudsburg, Pa. 18360 Telephone/fax: 570-992-3458 or e-mail:
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**************************************************************************************************************** LIABILITY OF WAIVER ( If downloading, this must be returned, signed with application! )
In consideration of your acceptance of my registration, I do hereby for myself and my heirs, executors and administrators waive, release and discharge forever any and all rights and claims for damages which I may have in connection with the tournament, have or incur and those which may be accrued to me against the WKUHOF ( World Karate Union Hall Of Fame), Frank and/or Kathi and/or Trevor Tasetano, the promoters and/or their heirs, the 13th Annual WKUHOF Karate Tournament, the Chateau Resort & Conference and/or their employees, the arbitrators, and/or leasees of premise, my personal representatives, assigns, heirs guardians and/or next of kin for any/all damages and any claim or demands therefore on account of injury to the person or property or resulting in the death of the undersigned, whether caused by negligence of releases, accident or otherwise while the undersigned is in or upon the restricted area and/or competing in, observing or working for, or any other purpose participating in this event. I also certify that I have NO MEDICAL CONDITION(S) that may or will cause injury to myself or others by my participation in the 13th Annual WKUHOF Karate Tournament. I also waive my rights to any compensation in the event my picture is used for publicity in connection with the tournament.
NAME:__________________________________SIGNATURE:_____________________ PARENT/GUARDIAN:_______________________________DATE:________________
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