Address_________________________________________________________________

City/State/Zip___________________________ Phone ___________________________

Country Name: _____________________________________

Sensei Name:______________________________________

Male____ Female____Birth-date_____________________________________________

Age: As of March 1st, 2008

LEVEL —(means years you have trained in martial arts) Please circle one:
Beginner (< 1 year) Novice (1 to <2 years)
Intermediate (2 to <3 years) Advanced (3+ years)
NOTE: NO brown belts in Beg/Nov divisions NO black belts in Beg/Nov/Int. divisions. YOU CANNOT COMPETE IN THE SAME SKILL LEVEL YOU DID LAST YEAR (exception…black belts or if you competed up in multiple divisions.) Anyone who does not circle a level will be place automatically in advanced division.

EVENTS (circle all that apply) KATA KUMITE KOBUDO

MANDATORY KATA (AGES 16 & UP ADV.)

(TEAMS REGISTER ON SEPARATE FORM)-(circle) TEAM NAME:___________________________________________

TEAM KATA TEAM KOBUDO TEAM KUMITE

TEAM FEES - $35 PER EVENT

INDIVIDUAL FEES – $45 first 3 events, $20 each additional event
Payable to: Champion Karate & Fitness

Money Orders or Credit Card Authorization Only, no personal checks, credit cards –
fax to 770-577-6050 or mail to:

Champion Karate& Fitness
2145B West County Line Rd.
Douglasville, GA 30135

RELEASE AND INDEMNITY
In consideration of the acceptance of myself or my child to participate in the 2008 Atlanta’s Champion Cup (Champs Cup) Karate Championships, I agree to assume the risks incidental to such participation (which risks may include, among other things, muscle injuries and broken bones) and, on my own behalf, and on behalf of my heirs, executors, and administrators, release and forever discharge the released parties defined below, of and from all liabilities, claims, actions, damages, costs or expenses of any nature arising out of or in any way connected with the participation of myself or my child in such activity and further damages, costs or expenses, including, but not limited to, attorney’s fees and disbursements. For this event, the released parties are the USA National Karate Do Federation, Champs Cup staff/volunteers, Champion Karate & Fitness, their parents, American Samurai, Georgia Karate League, related and affiliated companies, and the officers, directors, employees, agents, representatives, successors, volunteers, and assigns of each of the fore going entities. I understand that this release and indemnity agreement includes any claims based on the negligence, action or inaction of any of the above released parties and covers bodily injury (including death) and property damage, whether suffered by myself or my child, before, during, or after such participation. I understand that there are no refunds.I declare that I and/or my child is a member in good standing with the Amateur Athletic Union and is physically fit and has the skill level required to participate in this particular event. I further authorize medical treatment for my child or myself at my cost, if the need arises. I further grant the released parties the right to photograph and/or videotape me and further to use my name, face, likeness, voice and appearance in connection with the exhibitions, publicity, advertising, and promotional materials without reservation or limitation.
Signature of Competitor ___________________________________ Date ________________________________________
Signature of Parent (if competitor is under 18 years of age)

______________________________Witness:______________