2012 WTSDA W - The World Tang Soo Do Association
2012 WTSDA W - The World Tang Soo Do Association
2012 WTSDA W - The World Tang Soo Do Association
You also want an ePaper? Increase the reach of your titles
YUMPU automatically turns print PDFs into web optimized ePapers that Google loves.
<strong>2012</strong> <strong>WTSDA</strong> WORLD CHAMPIONSHIP<br />
ENTRY APPLICATION *<br />
All information below MUST be completed. Failure to complete ALL information may result in delayed<br />
processing and possible denial of application. (Please PRINT/TYPE LEGIBLY.)<br />
Last Name<br />
First Name<br />
Email<br />
Phone<br />
<strong>WTSDA</strong> #<br />
Date of Birth<br />
Weight<br />
Age<br />
Gender<br />
(check one) Male _____ Female _____<br />
Instructor<br />
CURRENT RANK (PLEASE CHECK ONE)<br />
Tiny Tiger / Little Dragon<br />
10 th Gup (White Belt)<br />
9 th Gup (White Belt w/ Stripe)<br />
8 th Gup (Orange Belt)<br />
7 th Gup (Orange Belt w/ Stripe)<br />
6 th Gup (Green Belt)<br />
5 th Gup (Green Belt w/ Stripe)<br />
4 th Gup (Brown Belt)<br />
3 rd Gup (Brown Belt w/ Stripe)<br />
2 nd Gup (Red Belt)<br />
1 st Gup (Red Belt w/ Stripe)<br />
Cho Dan Bo (Blue Belt)<br />
Cho Dan (1 st Degree Black Belt)<br />
E Dan (2 nd Degree Black Belt)<br />
Sam Dan (3 rd Degree Black Belt)<br />
Studio<br />
Special Needs / Specially<br />
Challenged<br />
Special Needs competitors please be sure to<br />
indicate your rank above.<br />
I will compete in the following categories (check all that apply):<br />
Forms (Hyungs) Sparring (Dae Ryun) Weapon Forms (Brown Belts and above only)<br />
I will be a member of the Creativity Team representing my studio:<br />
YES<br />
NO<br />
(If you fail to check a category you will not be able to compete in that area at the competition.)<br />
ENTRY FEES AND DEADLINES<br />
Application Postmarked By<br />
Competing Group March 15 April 15 May 15 June 1<br />
Youth/Adult/Senior $55 $65 $75 NA<br />
Tiny Tigers/Little Dragons $35 $35 $35 NA<br />
White Belts Joining After 3/31/12 NA $65 $65 $65<br />
(Pre-registration is MANDATORY, and all applications MUST be received in Headquarters or postmarked by the deadline<br />
dates. Absolutely NO entries will be accepted after the above deadline dates.)<br />
Number of shirts in each size<br />
OFFICIAL <strong>2012</strong> WORLD CHAMPIONSHIP T-SHIRTS<br />
Youth<br />
Adult<br />
M L S M L XL XXL XXXL<br />
Entry Fee (based on deadlines, see above) = $<br />
Total Number Unit Price<br />
Total T-Shirts #______ x $20 = $<br />
Additional Entrance Wristbands #______ x $5 = $<br />
Picnic Tickets (Adult) #______ x $15 = $<br />
Picnic Tickets (Child) #______ x $10 = $<br />
2010 <strong>World</strong> Championship DVD #______ x $10 = $<br />
30 years + Masters’ Dinner(Email address required) #______ x $75 = $<br />
TOTAL DUE (SEE NEXT PAGE) $<br />
Line Totals
<strong>2012</strong> <strong>WTSDA</strong> WORLD CHAMPIONSHIP<br />
ENTRY APPLICATION<br />
LAST NAME<br />
FIRST NAME<br />
I, the undersigned, for myself or on behalf of my minor child , any heirs, executors and administrators thereof, recognizing there is a risk of injury, do hereby waive,<br />
release and forever discharge any and all rights and claims for damages which I may have or which may accrue against the <strong>World</strong> <strong>Tang</strong> <strong>Soo</strong> <strong>Do</strong> <strong>Association</strong>, Inc.,<br />
its affiliates, officers, representatives, successors, officers of the Championship, my own studio, my own instructor, the Greensboro Coliseum, and their workers<br />
and/or successors or assigns and against any competitors for any and all injuries, losses, or damages, including, but not limited to personal injuries, property<br />
damage, or death, which may be sustained by me. I will obey all required rules and regulations and also assume full responsibility and liability for any of my<br />
actions during and in connection with this Championship. If I, or any of my guests, violate any <strong>WTSDA</strong> rules, I understand we will be ejected from the event,<br />
without a refund. I agree that my performance or attendance at the Championship, or both, may be filmed or otherwise recorded or telecast live, and I consent to<br />
the use by the <strong>World</strong> <strong>Tang</strong> <strong>Soo</strong> <strong>Do</strong> <strong>Association</strong>, its assignees and licensees including any public news media, of my name, likeness, voice, poses, pictures and<br />
biographical form or language with or without other materials, throughout the world without limitation, for television, radio and/or theatrical motion pictures by any<br />
devices now known or hereafter devised, and I waive any compensation whatsoever in connection with the foregoing and waive all rights to any intellectual<br />
property rights which may arise therefrom. I further understand and agree that all fees paid hereunder are NONREFUNDABLE.<br />
Date Signature (month of birth, if emailing)<br />
Date Signature of Parent/Guardian, if under 18 (month of birth, if emailing)<br />
PAYMENT INFORMATION<br />
Only completed applications with full payment will be processed.<br />
Payment Options: 1. Checks or money orders made out to <strong>WTSDA</strong> *<br />
2. Visa, Discover, or MasterCard(fill out below) **<br />
3. Payment through PayPal to wtsda@aol.com *** :<br />
CREDIT CARD PAYMENT INFORMATION:<br />
Name on Card: _________________________________________________________________<br />
Card # _____________________________________________ Exp. Date _____________________<br />
Security Code # (3-digit number on back next to signature) _____________________ Zip Code ______________<br />
Total amount to be charged to card: $___________________<br />
* If paying by check or money order (made out to <strong>WTSDA</strong>), please mail payment WITH completed application directly to<br />
<strong>WTSDA</strong>.<br />
** If you wish to pay by credit card, please complete the credit card payment information above.<br />
*** If you pay through PayPal, please write your PayPal account email address, and submit WITH your completed application<br />
via: Email: <strong>WTSDA</strong>@aol.com<br />
(Please use the SUBJECT line : Last name, First name, <strong>World</strong> Championship)<br />
Fax: (215) 336-2121<br />
Mail: Before March 31 st : <strong>WTSDA</strong>, 709 Oregon Avenue, Philadelphia PA, 19148<br />
After April 15 th : <strong>WTSDA</strong> 2436 Hanford Road, Burlington, NC 27215<br />
VOLUNTEER SIGN-UP!<br />
We need your assistance to make this historic event a success! Black belts in particular are encouraged to show<br />
their pride and honor by helping to insure we have a safe and professional event.<br />
I am competing at the <strong>World</strong> Championship<br />
I am NOT competing at the <strong>World</strong> Championship<br />
I CAN ASSIST IN THE FOLLOWING WAYS:<br />
Trained as a Score Keeper / Time Keeper<br />
Certified as a Corner Judge<br />
Certified as a Center Judge (Regional)<br />
Certified as a Center Judge (International)<br />
Other duties (describe):<br />
___________________________________________________________________________________________