(PLEASE PRINT CLEARLY)
First: _________________ Last : __________________________ Age As of (8/31/2007) : ______
Height : ______ Weigh t: ______ Gender : M / F Your Rank : Beg / Int / Adv / Black-Dan ____
Phone ( ) - Address : ___________________________________ City : ____________
State : ____ Zip : _________ AAU NUMBER - _______________________
Competing In : (please circle) FORMS POINT SPARRING OLYMPIC SPARRING
School Name : _______________ Instructor Name: _____________ School Phone ( ) -
Address : ___________________________________ City : ____________ State : ____ Zip : _________
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Competitor Fees: $65.00 All Events x ____ = $ ______
Spectator Fees: Adult Spectator $10.00 x ____ = $ ______
Child Spectator $7.00 x ____ = $ ______
Coaches Fees: Coaches Pass $10.00 x ____ = $ ______
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Competitor Fees & Spectator Fees - Total = $_______
All Spectator Tickets Are Pre-Purchase Price-They Will Be More The Day Of Competition!!!
NO PERSONAL CHECKS!! Bank Checks or Money Orders ONLY!!!
PLEASE MAKE ALL PAYMENTS OUT TO Robert Blum. ALL FEES ARE NON-REFUNDABLE!!
MAIL REGISTRATION TO:
JUST FOR KICKS MARTIAL ARTS, 982 MAIN ST., FISHKILL, NY 12524.
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INJURY
WAIVER
I, (Print full name)_________________________________________
the undersigned, do hereby release Just For Kicks Martial Arts Center, Shanely’s
Tae Kwon Do, Master Robert Blum, Master Brian Shanely, The American Martial
Arts Alliance, AAU, Best Western Inn & Conference Center, and all other
persons associated with this event in any capacity, from any liabilities due
to injuries, etc. that may occur as a result of my attendance and/or participation
at the Hudson Valley Challenge held at The Best Western Inn & Conference
Center on Saturday June 9 th , 2007. Furthermore, I hereby permanently waive
any compensation whatsoever for the use of pictures, videos, media coverage,
etc. utilized by those associated with this event which may be used for profit
making purposes or future publications. I clearly understand the fighting aspect
of this sport and competition involves bodily contact. I have read, understand
and agree to abide by the rules associated with AAU or AMAA Sanctioning and
Shanleys Tae Kwon Do & Just For Kicks events and assume all responsibility
and any associated liability for infringement of such rules. Additionally, I
am fully aware of my personal medical condition and physical limitations and
hereby certify that I am mentally and physically fit to compete at said tournament
and also understand that a valid birth certificate may be required to compete
at an AAU or AMAA tournament.
X_________________________________________ _______________ X______________________________________________
Signature Of Competitor Date Parent Or Guardian If Participant is under 18 yrs. old.