Kumite
Name: _____________________________________________________________________
Address: _____________________________________________________________________
City:_____________________________ Zip Code: ______Phone: _____________
School / Club: __________________________________________________________________ Rank: ______________ Instructor: ____________________________________________________
Kumite 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: _____
Men’s 18over:_____ 18 over Black Belt: _____ 35 over Black Belt: _____ 55 over Black Belt _____
Men’s 18over:_____ 18 over Black Belt: _____ 35 over Black Belt: _____ 55 over Black Belt _____
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.
MEDICAL COVERAGE?           _____YES     _____NO
MEDICAL PLAN __________________________                     COVERAGE # ________________
HOME PHONE:  _______________________EMERGENCY PHONE: ____________________       DOCTOR’S NUMBER: ________________________  HOSPITAL: __________________________
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 SIGNATURE                                  DATE      GUARDIANS SIGNATURE  DATE