Entry Form

Entry Form Name___________________________________________Age__________Rank_________ Address_________________________________ City___________________ State_____ Zip_______ Alliance Member #___________________ Style______________________________________ Karate School Instructor ___________________________Instructor___________________ Home Phone___________________ School (Dojo) Phone___________________ Email ______________________________________(if you want email contact)
Tournament Divisions (Please Circle the divisions you are entering)
Kata (Forms) Divisions Black Belt Men Sr. Black Belt Men* (35 & Over) Black Belt Women Brown Belt Men Brown Belt Women Sr. Kyu Men (35 & Over) Sr. Kyu Women (35 & Over) Colored Belt Men Colored Belt Women Novice Men Novice Women Young Men & Women (16-17) (Beg., Int., Adv.) Teens (14-15) (Beg., Int., Adv.) Juniors (12-13) (Beg., Int., Adv.) Youth (11) (Beg., Int., Adv.) Youth (10) (Beg., Int., Adv.) Tots (9) (Beg., lm., Adv.) Tots (8) (Beg., Int., Adv.) Tiny Tots (7) (Beg., Int., Adv.) Tiny Tots (6) (Beg., Int., Adv.) Mini Mites (5 & under) Weapons Black Belt Men Black Belt Women Adult Kyu Teen (14-17) (Beg., Int., Adv.) Youth (10-13) (Beg., Int., Adv.) Tots (9 & Under) (Beg., Int.*, Adv.)	Kumite (Sparring) Divisions Black Belt Men (Light, Middle and Heavy)* Sr. Black Belt Men* (35 & Over) Black Belt Women Brown Belt Men Brown Belt Women Sr. Kyu Men (35 & Over) Sr. Kyu Women (35 & Over) Colored Belt Men Colored Belt Women Novice Men Novice Women Young Men (16-17) (Beg., Int., Adv.) Young Women (16-17) (Beg., Int., Adv.) Teen Boys (14-15) (Beg., Int., Adv.) Teen Girls (14-15) (Beg., Int., Adv.) Junior Boys (12-13) (Beg., Int., Adv.) Junior Girls (12-13) (Beg., Int., Adv.) Youth Boys (11) (Beg., Int., Adv.) Youth Boys (10) (Beg., Int., Adv.) Youth Girls (11) (Beg., Int. , Adv. ) Youth Girls (10) (Beg., Int., Adv.) Tots Boys (9) (Beg., Int., Adv.) Tots Boys (8) (Beg., Int., Adv.) Tots Girls (9) (Beg., Int., Adv.) Tots Girls (8) (Beg., Int., Adv.) Tiny Tots (7) (Beg., Int., Adv.) Tiny Tots (6) (Beg., Int., Adv.) Mini Mites (5 & under) * 3 Competitors required to have separate divisions Youth Black Belts 6-17 years are in Advanced divisions for Kata Kumite Weapons

Hold Harmless Waiver I understand that karate is a contact sport. As such, I am aware that I am participating in an activity that involves physical contact and injuries may occur, which may potentially involve great bodily harm or even death and I do so at my own risk. I waive any claim or cause of action I may have against the promoters of the tournament, the judges, and other competitors, the United States Karate Alliance, IIMA, Keichu Karate of Vista, Dennis, Linda, and Jeff Crothers, and the City of San Marcos. I further agree to indemnify and hold harmless the promoters, judges, the United States Karate Alliance, IIMA, Keichu Karate of Vista, Dennis, Linda, and Jeff Crothers, and the City of San Marcos from any and all causes of action or claims which may arise from another competitor due to my participation or actions in this tournament. I state that I do not suffer from any physical and mental conditions, which may affect my participation in this tournament. I further agree to conduct myself in a sportsmanlike manner and understand that if I fail to do so, I may be disqualified from the tournament and not entitled to a refund. Signature:___________________________________________ Date:__________________
Mail pre-registration to: Crothers Keichu-Do 2095 Truesdell, • Carlsbad, Ca 92008