american kenpo schools of self defense
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Recol Pan American Tournament
Registration Form
F.B.B.A.#                                   No
   
Last Name:
First Name:
Middle Initial:
Address:
City:
State:
Zip:
Age:
Date of Birth:
Sex: M F
Telephone:
Rank/Belt:
Division Name:
School Name:
Instructor:
Address:
City:
State:
Zip:
Phone:

Check Each Division You Plan To Enter
Weapons Forms Fighting Open
Competitors Fee $40.00 (Open Divisions $5.00 Extra)
Friday: Spectator Fees
Day: Adult $5.00
Children $3.00		 Saturday Spectator Fees
Day: Adult $6.00
Children $3.00
Night: Adult $10.00
Children $5.00
Day and Night: Adult $12.00
Children $6.00
Competitors Free Night time show		 Competitors Fees
Weapons, Kata and Fighting $40.00
Open Division $5.00 extra
 
Hold Harmless Waiver and Statement
Parents: Please read and understand. Please bring birth certificate or passport of your child. If there is a problem or question of the height or age of your child and you do not have any proof of age with you, it will be at the discretion of the arbitrator and promoter as to where the child will be placed. This must and will be enforced. Absolutely no refunds!

I, the undersigned, do hereby voluntarily submit my application and participation in the above mentioned karate tournament held at the participating facility and do assume full responsibility for any and all damages, injuries, and losses that I may sustain individually or otherwise. I fully understand that any medical treatment given to me will be first aid treatment only. I consent that any picture taken of me in connection with the above mentioned karate tournament can be used for publicity, promotion, or television showing and waive compensation with regards thereto. I also certify that I will abide by the rules and regulations governing the above mentioned karate tournament and the interpretation of these as outlined by the promoters and their agents. Furthermore, I release the Florida Black Belt Association, Barbara Goleman High School and Ramada Inn, Promoter Manny Reyes, and all agents and assignees involved in the above mentioned karate tournament in any capacity from any liability due to injuries, etc. that I may incur as a result of my attendance and/or participation in this event. I clearly understand that the fighting aspect of this sport and competition involves bodily contact. I have read, understand, and will abide by the above and assume full responsibility and any associated liability for infringement of such rules. Additionally, I am fully aware of my personal medical condition and hereby certify that I am mentally and physically fit to compete at this F.B.B.A. event.

Signature of competitor (If over 18 years of age)____________________________
Date_________________________________

Signature of Parent or Guardian_________________________________________
Date_________________________________
Visit us on the web if you have any further questions at: www.worldkenpo.com
     
We Accept:
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american kenpo schools of self defense
  14427 Countywalk Dr.
Miami, FL 33186
(305) 255-8160

555 E. 25th St.,
Suite 214
Hialeah, FL 33013
(305) 696-0099

1550 W. 84th St.
Hialeah, FL 33014
(305) 825-2206
 
Hours: Mon-Fri 10:00 am - 9:00 pm

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