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2012 ITKA International Sima and Zahra Memorial Tournament
International Traditional Karate Association World Friendship Tournament
March 24th and 25th
Name: _________________________ Male/Female: ______________
Address: ___________________________________Phone: ________________
City: ____________ State: ______ Zip: _____Country: _________ Email: ______________
Work Phone: ______________________ Fax Number:______________
Dojo: _________________ Instructor: _____________________ Birthday: ______ Age _____
Rank(kyu): ___________ Height: _______ Weight _______ LBS. ____ KG. ____ (check one)
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Saturday March 24th:
Seminar, Judge's Clinic, Kata Competition and Kobudo Competition will be held the Main Dojo
5945 W. Irving Park Road Chicago, IL 60634
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□ I am attending Kata
□ Kumite
□ Kobudo
□ Team Kata Competition
Team Kata Members' Names (Fourth Person is Alternative):
1) ______________________ 2) ____________________
3)______________________ 4th:______________________
□ Kobudo Competition
Tournament Sunday, March 25th.
If you register by April 1st, 2011, take $5 off. Add $10 after April 4th
Family Discount: Families of two or more may subtract $10 per application
Circle the Appropriate Categories Below:
I am competing in the following:
Ages 7 and under
Ages 8-9 10th & 9th Kyu Individual Kata
Ages 10-12 8th & 7th Kyu Individual Kumite
Ages 13-15 6th, 5th, 4th Kyu Team Kumite (Adults only)
Ages 16-17 3rd, 2nd, 1st Kyu
Ages 18-44 1st Dan and up Kihon (10-7th Kyu Only)
Ages 45 & up
*Events/Divisions/Categories/Schedule are subject to change.*
Team Competition List Team Mates Below (4th competitor is alternative):
Team Kumite:
1) ____________________ 2) _____________________
3)______________________ 4th: _______________________
Amount Due:____________ NO REFUNDS
Whereas I, ____________, am applying for (Minor name here) ____________ to enter the ________ (date) Tournament Understanding the risks of injury, damages, or losses involved, hereby waive and forever release the ITKA, Wright College, all Clubs, and parties associated with aforementioned from any and all responsibility resulting in personal injury, concussion, broken bones, death, loss or damage to personal property or actions which might be taken against them in connection with my participation in said events. I waive full financial obligations incurred for medical, hospital and other expenses related to injury or death resulting from my participation in tournament or in traveling to, from or about the tournament. I release and hold harmless the ITKA, JKAI, Wright College, and all parties, their liability and claims for those expenses described above. I sign this release fully understanding the risk in my participation in said tournament or in tournament release activities. I further have read the foregoing and fully understand the contents of this release of indemnity.
I understand and assume all risks involved in participation in the tournament and tournament activities.
Signature: ____________________________ Date: __________
Signature of Guardian (under 18): _________________
Please make all checks payable to: ITKA Mail to: ITKA Headquarters 5945 W. Irving Park Road Chicago, IL 60634
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