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PLEASE PRINT:
Name:
___________________________________________________ Age:________ Birth Date:
________
IWKA #___________
Rank: _____________ Belt: ___________ eMail: ___________________________
Phone
#_____________ Address/City/State/Zip code:
__________________________________________
____________________________________________________________________________________
Instructor's Name &
Phone
______________________________________________________________________
Martial Arts
School’s Name & Phone # ___________________________ eMail:
_______________________
Address:
________________________________________________________________________________________
Division
# (See division listings and write number on lines below. For example…Forms/Kata:
K-4)
Forms/Kata _________ Sparring/Kumite _______ Weapons __________ |
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PLEASE SIGN WAIVER - FOR EACH COMPETITOR:
For the IWKA 2009 Championships Competition in Pittsburgh,
June 18, 19, and 20, 2009:
WAIVER: I
understand that the practice of Karate, and specifically, tournament
competition, is inherently a contact sport, and as such, know that
physical injury can occur. As consideration for being allowed to compete in
this tournament, I hereby assume all responsibility for
and all risk of damage or injury that may occur as a participant in this
tournament. Specifically, I agree to release and will hold
harmless and fully indemnify for any claims which might arise, the Isshinryu
Karate Academy of Pittsburgh or Hilton Hotel of Pittsburgh and any
persons affiliated with this tournament in any way from any and all claims
or causes of action on account of any injury or damage which may
occur from my participation in the IWKA World Championships Tournament. By
signing this document, I acknowledge that I
have read the rules and agree to abide by them and assume full
responsibility for any and all of my actions during this Tournament. If
under the age of 18 years, a parent or legal guardian must also sign this
waiver.
Print Competitor's Name:
__________________________________________ Date:______________
Parent/Guardian Self Signature:__________________________________ of
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