BELLIAREWUSHUACADEMYCHAMPIONSHIP

WHERE:BELLAIREFITNESSCENTER4330PANTHERDRIVEBOSSIERCITY,LA71112

WHEN:APRIL23,20168A.M-12P.M.

EVENTS:BASICMOVEMENTS,OPENHANDFORMS,WEAPONSFORMS,FLAG

SPARRINGANDPOINTSPARRING

FORAGES13ANDUNDER

EVENTFEES:$30FORTWOEVENTS

$5FORANYADDITIONALEVENTS

SPECTATORFEES$2APERSON

CHILDRENUNDERTHREEAREFREE

PRE-REGISTERBY:APRIL15,2016

Pleasefilloutlegiblyandmailyourform,alongwithyourpayment,totheaddressbelow:

BellaireWushuAcademy4330PantherDriveBossierCity,LA71112

Acceptedpaymenttypesforpre-registrationarecheck,moneyorderandcredit/debitcardIfpayingbycreditordebitcard,mailinyourpre-registrationinformationalongwithyourcredit/debitcardinformation,oryoumaycallBellaireWushuAcademyat318.470.1307

overthephone.

FORASCHEDULEGOTOwww.bellairewushuacademy.org

BellaireMaritalArtsChampionshipPre-RegistrationForm

Name__________________________________________________________________________________________________________

Address_______________________________________________________________________________________________________

City_____________________________________________________State____________________Zip_______________________

Telephone___________________________________________Or_____________________________________________________

Age_______________EmailAddress___________________________________________________________________________

Style____________________________________________________________Rank________________________________________

Instructor_______________________________________________InstructorsRank________________________________

SchoolName__________________________________________________________________________________________________

SchoolAddress________________________________________________SchoolPhone______________________________

City_____________________________________________________State______________________Zip______________________

Pleasechecktheeventsthatyouwillbecompetingin:☐Openhandforms☐Weaponsforms☐BasicMovements(3-5years)☐Pointsparring☐Flagsparring(3-5years) T-shirtsize(ForPre-registrantsonly):�YouthSmall� YouthMedium�YouthLarge� AdultSmall� AdultMedium� AdultLarge� AdultExtraLarge�Adult2XLRegulationMartialArtsUniform,HandPads,FootPads,Headgear,Mouthpiece,andGroinProtectorformalesarerequiredinalldivisions.Ihaveread,Iunderstand,andIagreetoabidebyalltherulesandregulationssetforthforthistournament.IunderstandthatthereisariskofpersonalinjuryinvolvedinthistournamentandwiththisknowledgeIagreetotakefullresponsibilityforanyofmyactions,andIagreetoindemnify,saveandholdharmlessBellaireWushuAcademy,itsstaff,instructorsandassistants,BellaireFitnessCenterandBellaireBaptistChurchandanyofitsstafforcomponentsfromanyandalllosesorclaimscausesbyaccidentorinjurytomeortoanythirdpersonswhomaybecompetitorsoraffiliatedwithandofthepreviouslynamedentitiesinanymanner,intheeventthatmyselforsaidthirdpersonisinjuredinanywayinthisevent.BecauseofthephysicaldemandsofMartialArtstournamentcompetition,IunderstandthatImustbeingoodphysicalconditionandthatIdonothaveamedicalconditionthatmayposearisktomyselfortoanyothercompetitorsduringthecourseofthisevent.Ifunder18yearsofage,thisreleaseandconsentmustalsobesignedbyaparentorguardian.______________________Date______________________________________________________________________________________________________SIGNATUREOFCOMPETITOR SIGNATUREOFPARENT/GUARDIAN