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COMPETITOR
INFORMATION
NAME -AGE(as of
1-1-07) -D.O.B. SEX -
ADDRESS
-PHONE #
-
CITY -ZIP -EMAIL -
MARTIAL ARTS INFORMATION
INSTRUCTOR -SCHOOL
-
SCHOOL ADDRESS - SCHOOL PH # -
BELT RANK - # OF YEARS
OF TRAINING -
CIRCLE 1 OF THE FOLLOWING: BEG. INT. ADV.
CIRCLE EVENTS YOU ARE DOING: -Kata -Point Spar -Creative Kata
Pre-Registration
Fee is $40 and must be postmarked by 08/01/07 for pre-reg. price to be
honored Make Checks
and Money Orders payable to: CMAA, 171 Lloyd Road, Lafayette, La. 70506 Registration
postmarked after 08/01/07 or at the door is $50 NO
CHECKS THE DAY OF THE EVENT!!
RELEASE FORM
I, the undersigned, release Champagne Martial Arts Academy, Johnathon Champagne, Comeaux Center, Southern Martial Arts Association
(SMAA) or any and all persons associated with this Tournament in capacity with any injury, etc. that I may incur as a result of my attendance
and /or participation in this Martial Arts event. Furthermore, I hereby wave any compensation whatsoever for the use of pictures or video, etc.
utilized by those associated with this tournament for promotions or profit, now and in the future.
I clearly understand that this sport involves special conditioning, which includes physically strenuous exercises and bodily contact.
I agree to abide by all rules of the Southern Martial Arts Association. I understand that I must wear the proper safety equipment while competing
in this event including mouthpiece, groin protector (cup) and full set of safety pads. I am fully aware of my personal medical condition and herby
certify that I am mentally and physically fit to participate in these events. I have read, understand,
and assume all responsibility and any associated liability.
Competitor
Signature -Parent/Guardian
Signature -
Date
-