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TOURNAMENT APPLICATION
Male Female Age:______Weight:________ Birthdate:___________ Date: ________
Beginner Novice Intermediate Advance
Name:_______________________________Address:
____________________________________
City:___________________________________State:___________Zip:_____________
Phone:____________________
Years of Training:__________Karate Rank:________________ Kyu: __________
Instructor’s Name____________________ School: ____________________________________
Division# Entered In: Fees Due:
K __________Kata All Individual Events: One Fee $50.00
S___________Kumite
W___ ______ Weapons Coaches Pass: $ 5.00
SP Sempai Kumite # of Coaches passes @ $5.00 ea ( )
SD White Belts Team Kata: Per Team $30.00
T Team Kata Team Name: __________________________
Late fee: $10 Applications faxed in by January 12, 2008 and paid by credit card, no late fee
charged.
Check ( ) Cash ( ) Money order ( ) (No personal checks after Jan 7,
2007) Total paid $ _____________
Credit card payment: Card # __________________________ expires: _______________
(mo/yr) Type_______ .
(No credit card payments after Jan 12, 2007)
Adult and Minor Amateur Athletic Waiver and Release of Liability
In consideration of being allowed to participate in any way in the New York City Liberty Classic
tournament and related events and activities, the undersigned:
1. Agrees that all competitors must exhibit behavior and manners consistent with the code of
“Karate-do” and good sportsmanship. Any acts or statements which are disruptive to the smooth
operations of the tournament or any division, or which are criminal insulting, offensive, or otherwise
seriously inappropriate may result in disqualification from the tournament.
2. No competitor will be allowed to compete where is appears that such a person has used, or is
under the influence of, any alcohol or illegal drug or medicine. Any competitor found in possession
of any alcoholic beverage, illegal drug, or narcotic substance at the tournament site may be
disqualified from the tournament.
3. All competitors will be required to appear for competitions at the posted times. Any person
who fails to appear when the division is called, or who fails to appear when their name is called in
the division, may be disqualified according to HKA rules.
4. All competitors must wear clean karate Gi(uniform).
5. ALL ENTRIES ARE FINAL UPON REGISTRATION.
6. Statement of Health: By my and/or Parent/ Guardian’s signature below I confirm that I am in
sound health and there is no reason why I cannot participate in this tournament and/or event.
7. I, hereby for myself, Harakenkojuku Martial Arts and Wellness Center, York College, Friends of
the School of the Moon and
Water, Volunteers and anyone else connected with the tournament, for any liability, injuries, I may
sustain, traveling to and
from and for participation in this karate event I have entered.
8. I recognize that traditional karate is a contact sport and I willingly participate in this event. In
addition, I hereby now and
forever, accept any and all responsibility for any action in conjunction with this event.
9. I also waive any compensation for the use of any pictures or videos taken of me at this event,
used directly or indirectly for
the promotion of future events.
The undersigned has read the above waiver and release, understand that they have given up
substantial rights by signing it and sign it voluntarily.
________________________________ __________________________ ________
Signature of Contestant Signature of Parent/Guardian Date
Please read the entire form before signing. All Information is Required.
Return by January 7, 2007, to:
Harakenkojuku Martial Arts Center, 197-17 Hillside Avenue, Holliswood, NY 11423.