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2013-BJJ-Pre-Reg.Pdf BJJ & GRAPPLING REGISTRATION Name_______________________ ________________________ male [ ] Female [ ] Weight________ Birth Date _____/_____/_____ Age __________ E-Mail_____________________________ (print neatly) Address_______________________________________ Home Phone ( ) ____________________ City____________________ State_________ Zip__________________ Years experience _________ Martial Arts School __________________ Instructor __________________ Team____________________ Is this your first Kumite Classic? [YES] [NO] Did you stay at the Double Tree? [YES] [NO] Did you: [Fly] or [Drive] Please Circle All That Apply: [Mailing List] [kumiteclassic.com] [flyer/postcard ] [mixedmartialarts.com] [Martial Arts School] How did you hear about the Kumite Classic? If Referral, Who?________________ Other______________ GI (Jiu-Jitsu) NO GI (Grappling) Cross Over Both BJJ & Grappling SELECT YOUR AGE CATEGORY: _____ Adult Male (18-29) Broken down by weight TOURNAMENT RELEASE AND WAIVER _____ Executive (30-39) Broken down by weight _____ Masters (40+) Broken down by weight _____ Women Broken down by age and weight _____ Teen (13-17) Broken down by age and weight I, (print name) ___________________________________________ the undersigned, hereby waive all claims against Kumite Classic En- _____ Youth (12-) Broken down by age and weight tertainment Corp., William Viola III, The Western Pennsylvania Police Athletic League Kumite International, The Monroeville Convention NO GI (GRAPPLING) EXPERIENCE: Saturday May 25th Center, and any and all other persons associated with this event in any _____ Novice: under 1 Year training (no wrestling experience) capacity from any and all liability due to injuries that I may incur as a _____ Intermediate: 1-3 years training result of my attendance and/or participation at this event. I understand _____ Advanced: More than 3 Years training the rules of the tournament and will abide by them. I understand that I am participating in a sport that has body contact. I assume full respon- GI (JIU-JITSU) EXPERIENCE: Saturday May 25th sibility for all of my actions during and connected to the above tourna- _____ WHITE ment. I understand the risk of competing in this form of Martial Arts _____ BLUE competition and hereby release the event organizers and all of its em- _____ PURPLE / BROWN / BLACK ployees and associates, tournament sponsors, and the event facility, from any type of injury, loss, or death sustained while competing in this Early Pre-Register: Before April 11th (get +free t-shirt) competition. I also state that I am in good mental and physical condition and know of no reason why I cannot participate in this Martial Arts One Event $55.00 (one event) event. I have current and valid health insurance. Divisions or weight Crossover +$15.00 (both Gi & No-Gi) classes are subject to change. In case of an emergency, I hereby au- thorize any licensed medical personnel to perform any accepted medi- Pre-Register: Before May 11th (post mark) cal procedure deemed necessary and I agree to bear the expense of One Event $60.00 (one event) any such treatment. I understand that a valid birth certificate may be Crossover +$20.00 (both Gi & No-Gi) required to compete at this event. I also agree that my attendance and/ or performance at the tournament may be photographed, filmed, or Registration: After May 11th or @ The Door (May 26th) taped and used by any schools and I waive any compensation thereof. One Event $75.00 (one event) I have read, understand and agree to abide by the rules associated Crossover +$25.00 (both Gi & No-Gi) with this event and assume all responsibility and any associated liability for infringement of such rules and sign below to complete this form: ALL postal mail must be post marked by May 11th After May 13th please signup @ the door. Pre-Register Money Order Payable To: _________________________________________________ “Kumite Classic” Competitors Signature Date 12421 St. Nikolai Dr. North Huntingdon, PA 15642 Always keep a copy of your money order receipt. We are not responsible for lost registration materials. If you wish to (cross over) and enter both Gi & No-Gi you must register for both at the $ same time to take advantage of discounted rates. *We reserve _________________________________________________ the right to expand, create, or combine divisions to accommodate Signature of parent / guardian who assumes competitors or special circumstances. Information subject to change at the discretion of the coordinator and head referee. Sorry no refunds for any reason. complete responsibility (if under the age of 18) Pre-register at your own risk. There are no substitutions or refunds for missing your divisions. Saturday May 25th 2103 - Monroeville Convention Center - Download Full Flyer www.kumiteclassic.com LIABILITY RELEASE, WAIVER, DISCHARGE AND COVENANT NOT TO SUE This is a legally binding liability release, waiver, discharge and covenant not to sue (the “Release”), made by me, the undersigned, to Kumite Classic Entertainment Corp. I, (PRINT NAME CLEARLY) _________________________________________, Fully recognize that there are dangers and risks to which I may be exposed by participating in the Kumite Classic Jiu-Jitsu and Grappling tournament, which involves strenuous physical activity and ex- tensive physical contact with other people and a mat, including but not limited to joint locks, throws, chokes, strikes, ground wrestling, and other similar activity. I understand and acknowledge that grap- pling and jiu-jitsu activities in general have inherent dangers that no amount of care, caution, training, instruction, supervision or expertise can eliminate. With full understanding of the risks involved and de- spite this Release, I am voluntarily entering the Kumite Classic. I therefore agree to assume and take upon myself all of the risks and responsibilities in any way associated with this activity. I release Kumite Classic Entertainment Corp., its agents, volunteers, and William Viola III from any and all liability, claims and actions that may arise from injury or harm to me, from my death or from damage to my property in connection with this tournament. I acknowledge and fully understand that I will be engaging in activities that involve risk of serious injury, and that severe social and economic losses may result not only from my own action, inactions or negligence, but also from the actions, inactions or negligence of other not- withstanding the rules of play or the condition of the premises or of any equipment used. Further I ac- knowledge and fully understand that there may be other associated risks with such activities that are not known or not reasonably foreseeable at this time. I understand that this Release covers liability, claims and actions caused entirely or in part by any acts or failures to act by Kumite Classic Entertainment Corp., its agents, volunteers, including but not limited to negligence, mistake, or failure to supervise. I recognize that this Release means I am giving up, among other things, rights to sue Kumite Classic En- tertainment Corp., its agents, and volunteers for injuries, damages, or losses I may incur while participat- ing in this tournament. I also understand that this release binds my heirs, executors, administrators, and assigns, as well as myself. I EXPRESSLY AND VOLUNTARILY ASSUMES ALL RISK OF PERSONAL INJURY, PERMANENT, TEMPORARY, TOTAL OR PARTIAL DISABILITY, DISFIGUREMENT, PARALYSIS AND ANY OTHER LOSSES OR DAMAGES TO PERSON OR PROPERTY OR DEATH, SUSTAINED WHILE PARTICI- PATING IN THE KUMITE CLASSIC, INCLUDING THE RISK OF PASSIVE OR ACTIVE NEGLIGENCE OF THE RELEASEES, OR HIDDEN, LATENT, OR OBVIOUS DEFECTS IN THE FACILITIES OR EQUIPMENT USED. I HEREBY FOREVER RELEASE, DISCHARGE AND COVENANT NOT TO SUE KUMITE CLASSIC ENTERTAINEMNT CORP. I ACKNOWLEDGE THAT I HAVE HAD SUFFICIENT OPPORTUNITY TO REVIEW THE PROVISIONS OF THIS DOCUMENT AND UNDERSTAND ITS PURPOSE, MEANING AND INTENT. I HAVE READ THE ENTIRE RELEASE, I FULLY UNDERSTAND IT, AND I AGREE TO BE LEGALLY BOUND BY IT. THIS IS A RELEASE OF YOUR RIGHTS. READ CAREFULLY BEFORE SIGNING. ______________________________________ _______________ Releaser’s Signature Date ______________________________________ ______________________________ Parent’s or Guardian’s Signature, if a minor (under 18) Witness IMPORTANT INFORMATION Event: 14th Annual Kumite Classic Promoter: Kumite Classic Entertainment Corp Director: Bill Viola Telephone: 724-861-5162 Monroeville Convention Center E-Mail [email protected] Website www.kumiteclassic.com Venue: Monroeville Convention Center Date: Memorial Day Weekend 209 Mall Boulevard Friday May 24th: Early Weigh-ins Monroeville, PA 15146 Saturday May 25th GI BJJ Divisions Free Parking Saturday May 25th NO GI Grappling Hotel: Double Tree Monroeville *competitors can weigh-in early Friday night or Saturday morning. 412-373-7300 101 Mall Boulevard Monroeville, PA 15146 Adjacent to convention center *Double Tree will sell out quickly, book in advance! Must mention “KUMITE CLASSIC” Room Block Kumite Discount rooms: $124.00 Reservation Deadline May 12th AIRPORT: Pittsburgh International (PIT) Overflow Hotel: Holiday Inn: 412-372-1022 Kumite Discount Rooms: $124.00 SPECTATOR FEES: General Admission Friday $10.00 FRIDAY MAY 24th General Admission Saturday $15.00 *Competitors receive free expo admission all weekend Registration & Early Weigh-ins 2pm-6pm Consumer Expo 4pm-9pm IMPORTANT INFORMATION You may register at the door All postal Pre-Registrations or Registrations: SATURDAY
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