2009 IWKA World Championship Tournament

Print NameHere:

QTY

SMART PRE-REGRISTRATION

By July 1, 2008

EARLY REGESTRATION

By Jan 1, 2009

LATE

REGISTRATION

June 1, 2009

AMOUNT

TOURNAMENT FEES

     One Event

$40.00

$50.00

$55.00

     Two or More Events

$50.00

$65.00

$70.00

Thursday Brown & Black Belts

     Master Duessel Seminar

$15.00

$20.00

$20.00

Friday:  Mstr. Shimabuku Seminars:

                 Brown & Black Belts

$15.00

$17.50

$22.50

                 All Ranks

$15.00

$17.50

$22.50

                 Both Friday Seminars

$20.00

$25.00

$35.00

DINNER: How many:

     ___ Adults ___Children Ages 12 under

  Please Indicate How Many of Each:

     ___Chicken ___Fish ___Vegetarian

  Wine Toast (circle)   ---Red   or  ---White

            (Must be 21 or older)

Circle: I plan to register at --Hilton --Other

     To register at Hilton after 7/1/08 use

     IWKA2009 for "BLOCK" promised rate  

     of $124.00 plus tax/fees.

      SEE HOTEL  ACCOMODATIONS

T-Shirts:

   Please Indicate Sizes and #s

      Adults:  2X__1X__Lg__ Md__ Sm__

      Children Lg__ Md__ Sm__

$10.00

$10.00

$10.00

Spectator Fee:     (At the door $10.00)

$8.00

$ 8.00

$ 8.00

       TOTAL ENCLOSED

PLEASE PRINT:

Name: ___________________________________________________ Age:________ Birth Date: ________

IWKA #___________  Rank: _____________  Belt:  ___________ eMail: ___________________________

Phone #_____________     Address/City/State/Zip code: __________________________________________

 ____________________________________________________________________________________

Instructor's Name & Phone

______________________________________________________________________

Martial Arts School’s Name & Phone # ___________________________ eMail: _______________________

 Address:

 ________________________________________________________________________________________

 Division # (See division listings and write number on lines below. For example…Forms/Kata:  K-4)

       Forms/Kata _________   Sparring/Kumite _______ Weapons __________

PLEASE SIGN WAIVER - FOR EACH COMPETITOR:

For the IWKA 2009 Championships Competition in Pittsburgh, June 18, 19, and 20, 2009:

WAIVER:  I understand that the practice of Karate, and specifically, tournament competition, is inherently a contact sport, and as

such, know that physical injury can occur.  As consideration for being allowed to compete in this tournament, I hereby assume all

responsibility for and all risk of damage or injury that may occur as a participant in this tournament. Specifically, I agree to release

and will hold harmless and fully indemnify for any claims which might arise, the Isshinryu Karate Academy of Pittsburgh or Hilton Hotel of Pittsburgh  and any persons affiliated with this tournament in any way from any and all claims or causes of action on account of any injury or damage which may occur from my participation in the IWKA World Championships Tournament. By signing this document, I acknowledge that I have read the rules and agree to abide by them and assume full responsibility for any and all of my actions during this Tournament.  If under the age of 18 years, a parent or legal guardian must also sign this waiver.

Print Competitor's Name: __________________________________________      Date:______________ 

Signature:__________________________________of Parent/Guardian:_____________________________________