FIRST NAME:
LAST NAME:
ADDRESS:
CITY:
STATE:
ZIP:
HOME PHONE: - -
FAX #: - -
EMAIL:
AGE:
BIRTH DATE: Month:   Day: Year:
GENDER: Male   Female
RANK:
WEIGHT: (lbs.)
INSTRUCTOR:
SCHOOL INFORMATION
SCHOOL:
 ADDRESS:
CITY:
STATE:
ZIP:
PHONE #: - -

 

 

Please Check ALL Events You Are Entering

FRIDAY NIGHT EVENTS
Super Seminars DemoTeam

Extreme Forms (Music Optional)

Team Sparring
Extreme Weapons (Music Optional) Continuous Kick Boxing
Musical Forms Breaking
Musical Weapons Black Light Competition
Synchronized Forms First Time Competitor Forms
SATURDAY DAY EVENTS
Creative Forms (Music Optional) Self-Defense
Creative Weapons (Music Optional) Points Sparring
Traditional Forms Kendo
Traditional Weapons
 

 

 

Ticket Information

If Pay by 5/31/2005

Day of Event

# of Events/ Participants

1st Individual Event:

$45.00

$55.00

$

Additional Individual Events:

$10.00

$15.00

$

Demo Teams:

$20.00

$30.00

(per member)

$

Team Sparring:

$20.00

$30.00

(per member)

$

Super Seminars:

$25.00

$35.00

(per member)

$

Friday Night Spectator:

  $8.00

$10.00

$

Saturday Day Spectator:

  $8.00

$10.00

$

Night Show Only Spectator:

  $8.00

$10.00

$

2-Day Spectator Pass:

$12.00

$15.00

$

Night Show Gold (rows 2-5): $20.00 $25.00

$

Night Show Ring Side: $35.00 $40.00

$

5 or More Students Special Rate:

$55.00  (for 3

events)

Pre-reg. only

$

5 or More Students Additional Events:   $5.00 (each) Pre-reg. only

$

(Must Register as a Group):

TOTAL $

                      

 

 

Waiver of Injury
I hereby release and agree to hold harmless the promoters, Danny and Theresa Zaino, owners and lessees of the premises, participant officers, directors, officials, representatives, agent and employees of all of them (NPL/FPCKE, Pepsi Cola America, FST,  FBBA, NASKA) from any loss, damage or injury (including death) to my person, children and property, in any way resulting from or arising in connection with this or any cause whatsoever.  I know the risk and danger to myself, children and property while on said premises or while participating or assisting in this event so, voluntary and in reliance, upon my own judgment and ability, I hereby assume all risk for loss, damage or injury (including death) to myself, children and my property from any cause whatsoever.
* Signature of Competitor or Guardian if under 18:
(for Waiver of Injury)

 

Payment Information

Selecting the "submit" button enters you in the events selected above.  To qualify for the discounted prices, you must make your payment by the discount date. To pay, You can either call in your credit card number to the school, bring a check or cash by the school, or select to pay by internet using the "PayPal" button below. 

Credit Card Fee: $
Total if paid by credit card: $

                                                       
 

This document will not be "signed" in the sense of a traditional paper document. By clicking the "PayPal buy now" button,  you are agreeing to incur all fees and costs.  This is a binding document.