Pre-Registration Form
Mail Pre-Registration Form to:
Donald McCluney, 1334 Clairmont Dr., Shelby NC 28150
Make certified checks or money orders out to Donald McCluney.
NO CHECKS WILL BE ACCEPTED!

$40.00 for 1 event & 10.00 for each additional event. Please return by February 20, 2010. Bring birth certificate for age verification. Please print the following form and mail to Donald McCluney at the above address before Feb. 20, 2010.

Name: ________________________________________ DOB ____________ Age ____ M ____ F ____

Address: _______________________________________ City ___________________________

St. _____ Zip ___________ Phone: ______________________ Belt __________________

Nov. ____ Int. ____ Adv. ____ BB ____     Instructor: _____________________________________

Studio Address: ________________________________________________________________________

Studio Phone: _______________________________

*** Please list division numbers for all divisions you are competing in: See Division List on next page. Breaking, Self-Defense, Musical, BB Musical Weapons 17-, Trad. Forms, Open Weapons, Open Forms, Handicapable Form/Weapons, Sparring.

1. __________ 2. __________ 3. __________ 4. __________ 5. __________ 6 __________ 7. __________ 8. __________

1 event $40.00 ___________, plus ____________ x $10.00 per additional event = Total $_____________

Coach's Pass (Addition to Spectator Fee) $15.00 __________ Spectator Fee __________ x $10.00 =  Total $__________

After Feb. 20, 2010: 1 event $45.00 __________ plus __________ x $15.00 per additional events = Total $__________

Release/Waiver

I, the undersign, do hereby voluntarily submit my application for attendance/participation in Donald McCluney's Annual Mid-Cleveland Karate Championships and do hereby assume full responsibility for all damages, injuries and losses that I may sustain or incur in any way while attending and participating in this event. I also waive all claims against the Promoter, the City of Shelby/the Shelby City Parks and Recreation or anyone directly or indirectly associated with this tournament for any claim or injury that I may sustain.

Signature of Competitor
(Parent if competitor is under 18) _____________________________________________ Date _____________________________
 
 

Divisions