Self Defense:
Name: _____________________________________________________________________
Address: _____________________________________________________________________
City:_____________________________ Zip Code: ______Phone: _____________
School / Club: __________________________________________________ Rank: ______________
Instructor: _____________________________________________________________
MEDICAL COVERAGE?           _____YES     _____NO
MEDICAL PLAN __________________________                     COVERAGE # ________________
HOME PHONE:  __________________             EMERGENCY PHONE: ______________                     
DOCTOR’S NUMBER: ________________________
Self Defense Division:
6, 7, 8: _____ 9, 10, 11: _____ 12, 13, 14: _____ 15, 16, 17: _____
Women 18 over: _________ 35 over Women Black Belt: _____
Men Black Belt: __________ 35 over Men 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.


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