City:_____________________________ Zip Code: ______Phone: _____________
School / Club: _____________________________________________________________________
Rank: ______________ Instructor: ____________________________________________________
MEDICAL COVERAGE? _____YES _____NO
MEDICAL PLAN __________________________ COVERAGE # ________________
HOME PHONE: __________________ EMERGENCY PHONE: _____________
DOCTOR’S NUMBER: ___________________
Weapon Kata Divisions:
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 GUARDIAN’S SIGNATURE DATE