2012 wtsda world championship - The World Tang Soo Do Association

2012 WTSDA WORLD CHAMPIONSHIPENTRY APPLICATION *All information below MUST be completed. Failure to complete ALL information may result in delayedprocessing and possible denial of application. (Please PRINT/TYPE LEGIBLY.)Last NameFirst NameEmailPhoneWTSDA #Date of BirthWeightAgeGender(check one) Male _____ Female _____InstructorCURRENT RANK (PLEASE CHECK ONE)Tiny Tiger / Little Dragon10 th Gup (White Belt)9 th Gup (White Belt w/ Stripe)8 th Gup (Orange Belt)7 th Gup (Orange Belt w/ Stripe)6 th Gup (Green Belt)5 th Gup (Green Belt w/ Stripe)4 th Gup (Brown Belt)3 rd Gup (Brown Belt w/ Stripe)2 nd Gup (Red Belt)1 st Gup (Red Belt w/ Stripe)Cho Dan Bo (Blue Belt)Cho Dan (1 st Degree Black Belt)E Dan (2 nd Degree Black Belt)Sam Dan (3 rd Degree Black Belt)StudioSpecial Needs / SpeciallyChallengedSpecial Needs competitors please be sure toindicate your rank above.I will compete in the following categories (check all that apply):Forms (Hyungs) Sparring (Dae Ryun) Weapon Forms (Brown Belts and above only)I will be a member of the Creativity Team representing my studio:YESNO(If you fail to check a category you will not be able to compete in that area at the competition.)ENTRY FEES AND DEADLINESApplication Postmarked ByCompeting Group March 15 April 15 May 15 June 1Youth/Adult/Senior $55 $65 $75 NATiny Tigers/Little Dragons $35 $35 $35 NAWhite Belts Joining After 3/31/12 NA $65 $65 $65(Pre-registration is MANDATORY, and all applications MUST be received in Headquarters or postmarked by the deadlinedates. Absolutely NO entries will be accepted after the above deadline dates.)Number of shirts in each sizeOFFICIAL 2012 WORLD CHAMPIONSHIP T-SHIRTSYouthAdultM L S M L XL XXL XXXLEntry Fee (based on deadlines, see above) = $Total Number Unit PriceTotal T-Shirts #______ x $20 = $Additional Entrance Wristbands #______ x $5 = $Picnic Tickets (Adult) #______ x $15 = $Picnic Tickets (Child) #______ x $10 = $2010 World Championship DVD #______ x $10 = $30 years + Masters’ Dinner(Email address required) #______ x $75 = $Line Totals0000000TOTAL DUE (SEE NEXT PAGE) $0

2012 WTSDA WORLD CHAMPIONSHIPENTRY APPLICATIONLAST NAMEFIRST NAMEI, 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,release and forever discharge any and all rights and claims for damages which I may have or which may accrue against the World Tang Soo Do Association, Inc.,its affiliates, officers, representatives, successors, officers of the Championship, my own studio, my own instructor, the Greensboro Coliseum, and their workersand/or successors or assigns and against any competitors for any and all injuries, losses, or damages, including, but not limited to personal injuries, propertydamage, 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 myactions during and in connection with this Championship. If I, or any of my guests, violate any WTSDA rules, I understand we will be ejected from the event,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 tothe use by the World Tang Soo Do Association, its assignees and licensees including any public news media, of my name, likeness, voice, poses, pictures andbiographical form or language with or without other materials, throughout the world without limitation, for television, radio and/or theatrical motion pictures by anydevices now known or hereafter devised, and I waive any compensation whatsoever in connection with the foregoing and waive all rights to any intellectualproperty rights which may arise therefrom. I further understand and agree that all fees paid hereunder are NONREFUNDABLE.Date Signature (month of birth, if emailing)Date Signature of Parent/Guardian, if under 18 (month of birth, if emailing)PAYMENT INFORMATIONOnly completed applications with full payment will be processed.Payment Options: 1. Checks or money orders made out to WTSDA *2. Visa, Discover, or MasterCard(fill out below) **3. Payment through PayPal to wtsda@aol.com *** :CREDIT CARD PAYMENT INFORMATION:Name on Card: _________________________________________________________________Card # _____________________________________________ Exp. Date _____________________Security Code # (3-digit number on back next to signature) _____________________ Zip Code ______________Total amount to be charged to card: $___________________ 0* If paying by check or money order (made out to WTSDA), please mail payment WITH completed application directly toWTSDA.** If you wish to pay by credit card, please complete the credit card payment information above.*** If you pay through PayPal, please write your PayPal account email address, and submit WITH your completed applicationvia: Email: WTSDA@aol.com(Please use the SUBJECT line : Last name, First name, World Championship)Fax: (215) 336-2121Mail: Before March 31 st : WTSDA, 709 Oregon Avenue, Philadelphia PA, 19148After April 15 th : WTSDA 2436 Hanford Road, Burlington, NC 27215VOLUNTEER SIGN-UP!We need your assistance to make this historic event a success! Black belts in particular are encouraged to showtheir pride and honor by helping to insure we have a safe and professional event.I am competing at the World ChampionshipI am NOT competing at the World ChampionshipI CAN ASSIST IN THE FOLLOWING WAYS:Trained as a Score Keeper / Time KeeperCertified as a Corner JudgeCertified as a Center Judge (Regional)Certified as a Center Judge (International)Other duties (describe):___________________________________________________________________________________________