Competitor Registration Form

Name:
Gender: M or F
Address:
City:
State: Zip code :
E-mail:
Day phone:
Evening phone:
Emergency contact :
Phone emergency:

School Name :
Phone:
School Address (in full):
Instructor's Name:
Date of birth : Age:
Weight: lbs
Belt: (specify color only)
Dan: (black belts only)

Registration Fee: $75

Please register for only one (your preferred) age category in order to help guarantee that every competitor gets a match. Please provide us with the following information.

  • Master and Senior Only - If no competitor register for your age and weight division, or the weight division above yours in your age category, are you willing to fight down one age division?

    Yes or No.
  • Junior Only - OPEN CLASS?

    Yes or No.
  • This question applies to All Age's Categories - If no other competitor register for your weight division, are you willing to fight up one weight category?

    Yes or No.

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The First 100 competitors will receive an official T-Shirt Event.

T-shirt size
Kids small medium large
Adults small medium large x-large double x -large