Type your paragraph here.

Kenpo Kata

Name: _____________________________________________________________________

Address: _____________________________________________________________________

City:___________________________ Zip Code: ______Phone: _____________

School / Club: ________________________________________________

Rank: ______________

Instructor: _____________________________________________________________

MEDICAL COVERAGE?      _____YES     _____NO

MEDICAL PLAN _______________________COVERAGE # ________________

HOME PHONE:  _____________________

EMERGENCY PHONE: ________________         
DOCTOR’S NUMBER: ________________________

Kenpo Kata Division:

Boys: 6, 7, 8: _____ 9, 10, 11: _____ 12, 13, 14: _____ 15, 16, 17: _____

Girls: 6, 7, 8: _____ 9, 10, 11: _____ 12, 13, 14: _____ 15, 16, 17: _____

Women’s Color belt 18over:_____

Women  Black Belt: ____ 35 & over: _____ 55 & over ____

Men’s Color belt 18over:_____                    

Men  Black Belt: _____ 35 & over: _____ 55 & over ______

A minimum of 3 contestants is required to run a division.  If there are not enough contestants the lower division maybe moved up to the next division.

WAIVER
I, the undersigned, do hereby voluntarily submit this application form to participate in this tournament.  I, the undersigned, do hereby assume full responsibility for any and all legal damages, injuries or losses that may be sustained or incurred.  I, the undersigned, do hereby waive all legal claims against San Sei Bu Self Defense Systems, all instructors, representatives, promoters, operators, sponsors, students, its agents, State of Hawaii, City and County of Honolulu and their facilities used for the use of this tournament.  I understand that any medical treatment given to me will be of a first aid treatment only.  I consent that any pictures furnished by me or any pictures taken of me in connection with San Sei Bu Self Defense Systems cannot be used for publicity, promotion and/or television showing, and I waive compensation in regard thereto.

If under age 18, this release and consent is to be signed by parent or guardian.

____________________________________________________   _______________
APPLICANT SIGNATURE                                                          DATE

_________________________________________________   _________________
PARENT / GUARDIAN’S SIGNATURE                                      DATE