Katsu Challenge Registration Form

Tournament Date 03/08/2020

Division Information

To receive the free T-Shirt, you must have registered by 02/24/2020!
 
 * Age is how old you will be on the day of the tournament
 * Black Belts must register as Advanced
 * Brown Belts must register as Intermediate or Advanced
 * Must Register by 02/24/2020 to receive free T-Shirt
 * Registration ends 3/05/2020
  
Total Fee ($) :
 

Billing / Contact Information
(must match name on Credit Card)

 
First Name Last Name
Address 1
Address 2
City State Zip
Phone
   
Email Address

Dojo Information
 

 
Dojo List
Dojo Name
Instructor Name
Dojo Address 1
Dojo Address 2
City State Zip
Dojo Phone Dojo Fax
       
Dojo Email Address Dojo Website

Medical Release / Treatment Permission Form

 

Please complete entire form, items that are not applicable, indicate with N/A. Do not leave any fields blank. Failure to complete all information may disqualify you from the tournament.

I hereby give permission, in the event that I (or my child) an unable to make a conscious medical decision for treatment, to Chief Instructor/Director Jason Sorgi and /or the tournament medical staff, of the Japan Karate Do, LLC, to act on my (or my child's) behalf and in my best interest, to receive any medical care they deem necessary.

I have read, understand and agree to the above statement
  Emergency Contact Name    Phone    
 
Underage Competitors (under the Age of 18 years old)
  Parent's or Guardian's Phone #:    
 
 
 

Medical Information (must be completed - Do not leave blank, if it does not apply write NONE)

List any possible life threatening or serious medical conditions:

List any known allergies

List any medications being used

Release, Discharge, Covenant

I hereby for myself, my executor(s), my heirs, forever and always agree to save and hold harmless Jason Sorgi, Japan Karate Do, LLC, the University of Florida, the Florida Sport Karate League, Katsu Challenge employees, officers, volunteers, workers, members, the facility owners, their respective officers, agents, successors and anyone else involved in the conduct of this Tournament for any liability or injury I may sustain by the way of my traveling to and from activities associated with participating or other direct involvement in the Katsu Challenge that I have registered here forth.

I hereby also certify that I know and understand the rules, policies, and code of conducts for my sport. I agree to allow, without compensation, the unrestricted use of any photographs, films or videotape of myself.

Submission of Registration and Payment certifies that you agree to All Risk in connection with your participation and have read and understand the contents of the above mentioned release for this event and agree to the full release of any and all claims. This also certifies that you understand there are no refunds once payment is submitted.

 

I have read, understand and agree to the above statement