2010 State Finals Pre-Registrations Form

Deadline Jan. 14, 2011

TO Print PDF:

state_finals/TKO INFO/TKO state flyer 2010.pdf

See you At State!!!

              Please provide the following contact information:
First name Last name
Address
City, State Zip
Rank Age as of      1-10-2010
DateOfBirth Sex Male Female
Height Weight
Home Phone Work Phone
E-mail    
            Please provide the following contact information:
Club Name
Instructor's Name
Street address
City/State/Zip
Club Phone
Club E-mail
          
          
            Please enter the CODE NUMBER OF DIVISIONS you are competing in. Number listed above
            Example:  W-1,  F-4,  F-22, ect...  
            1st Event 2nd Event 3rd event 4th Event
 
            Please provide the following ordering information:
QTY DESCRIPTION (Must be Received before Jan 14th) 
 Number of  Events Entering ( Your card will be billed $35.00 for 1 events and $25.00 for each additional )
Number of DAYTIME SPECTATOR (Your card will be billed for $10 for each spectator)
Number of COACHES PASS (Your card will be billed for $5 for each pass) 
Number of VIDEO PASS (Your card will be billed for $5 for each pass)
Number of TKO State Champion T-Shirt (Your card will be billed for $10 for each T-shirt)
Demonstration Div. Everyone Gets a Trophy win or lose! (Your card will be billed for $10)
TOTAL DOLLAR AMOUNT  (add your Total Dollar amount which you are paying)
 
SPECIAL COMMENTS IF ANY:
 

LIABILITY WAIVER. I do hereby voluntarily submit my application for participation in the "TKO State Championship" martial arts tournament and hereby assume full responsibility for any and all damages, injuries, or losses that I may sustain or incur, if any, while attending or participating and I waive all claims for/or against the promoters, or operator, or sponsors of said Martial Arts Tournament, individually or otherwise for any claims for injuries that I may sustain. I fully understand that I am entering such competition at my own risk, and that any medical treatment given to me will be of a first aid treatment type only. I declare that I am free of any physical defects or illness that might prohibit competition. I consent that any picture furnished by me or any picture taken of me in connection with the tournament can be used for publicity, promotion, or television shows, and I waive compensation in regards thereto, if under 18, this release and consent must be signed by parent or guardian. I further agree to abide by the rules of the tournament and the final decision of the officials. I certify that the above information is current and accurate to the best of my knowledge. I am a GUARDIAN or PARENT of the undersigned minor, I furthermore acknowledge that the waivers, releases, and affirmations stated above apply to said minor I made such in behalf of said minor as the parent or legal guardian of said minor.  I furthermore agree that by submitting this form that I accept all of the above conditions. 
 I also understand that this is an non-refundable transaction. As the authorized holder of the credit card described herein, I authorize , TKO martial arts to charge my credit card for Internet Web hosting services.
 
IMPORTANT!!!
You must complete and submit the online registration first before using Paypal.  Click the PAYPAL icon below to send your payment.  It is Free and the fastest, safest way to send money!  Send your payment to TKOKick@yahoo.com   
Please fill in the Paypal Sender's Name and Senders Email below, so we can match competitor to the Paypal sender.  Your payment is your receipt!  Thank You!
 
 
Name of Paypal Sender  Email of Sender

Credit or debit card through PayPal