PRODUCTION OF:
FAMILY TAEKWONDO INC.,
NORTH ROCKLAND
SHOTOKAN KARATE AND TEAM BARROSO
BREAKING THRU ROCKLAND MARTIAL ARTS
TOURNAMENT
DATE: Saturday, April 9th,
2005
PLACE: Village
of Haverstraw Community Center
50 West Broad Street, Haverstraw,
NY 10927
Time:
Registration Starts at 8:00 A.M.
Black Belt Meeting at 9:30 A.M.
Tournament Begins at 10:00 A.M.!! SHARP!!
Entry Fee:
Pre registration by April 2, 2005
1st event $40.00 / $5.00 each additional event
At the Door: 1st event $45.00 / $5.00 each additional event
Spectators: $5.00 Adults
$2.00 Children 10 years and under
Events:
Forms – Breaking – Point Fighting – Continuous Fighting – Grappling
Self-Defense.
Name: _______________________________ Age:
_____ Sex: ______
Address: _____________________________ City: _________________
State_______
School/Club name: _____________________________
Phone ____-______________
Instructors Name: ______________________________
Your Rank/Dan____________
WAIVER:
In consideration of being allowed to participate, the undersigned docs hereby voluntarily submit their application
and participation for Family Taekwondo Inc., North Rockland Shotokan Karate, and Team Barroso. The undersigned does hereby for himself, his heirs, executors, administrations successors
and assigns release and forever discharge the promoters and the organizers of the said tournament and their servants and agents
and all those in any way connected with the running and management of same, including the Village of Haverstraw Community
Center, Markel Agency and Family Taekwondo Inc., North Rockland Shotokan Karate, Team Barroso from any and all actions, cause
of actions, claims and demands for, upon and by reason of any damage, loss or injury to person and property and death, which
heretofore has been undersigned participating in the said tournament. I also,
hereby agree that the tournament directors for publication, broadcasting or any other promotional purposes may use any photographs
or films of myself taken at the event. I am fully aware of my personal physical
and medical condition, and hereby acknowledge that I am physically fit to compete in this martial arts tournament. I have read the rules personally or have been instructed by my teacher, Sensei, adult guardian or parent. As to the rules governing Family Taekwondo Inc., Village Community Center, North Rockland
Shotokan Karate, Team Barroso and Breaking Thru Rockland Tournament, I am fully prepared to follow the rules in a safe and
disciplined fashion.
X______________________________________ X______________________________
Student’s Signature (21 & Over)
Signature of parent or Guardian if under 21
(Please
Xerox for addition copies)
Please Do Not Write below this line. For our Purpose Only:
Adv. Spec. Tickets: _________ Adults: ________
Children (Date rec’d _______Ck.# _________ M.O._________ Cash ________
DIVISIONS
KATA, KUMITE, SELF DEFENSE:
SUPER PEE WEE 6 yrs and under
Beginners, Intermediate
PEE WEE
7, 8, 9 yrs old
Beginners, Intermediate
YOUTH
10, 11, 12 yrs old
Beginners, Intermediate, Advanced, Black Belt
TEENS
13, 14, 15 yrs old
Beginners, Intermediate, Advanced, Black Belt
JUNIORS
16, 17 yrs old
Beginners, Intermediate, Advanced, Black Belt
ADULTS
18-34 yrs old
Beginners, Intermediate, Advanced, Black Belt
SENIORS
35 and over
Beginners, Intermediate, Advanced, Black Belt
BREAKING:
SUPER PEE WEE 6 yrs and under
Beginners, Intermediate
PEE WEE
7, 8, 9 yrs old
Beginners, Intermediate
YOUTH
10, 11, 12 yrs old
Beginners, Intermediate, Advanced, Black Belt
TEENS
13, 14, 15 yrs old
Beginners, Intermediate, Advanced, Black Belt
JUNIORS
16, 17 yrs old
Beginners, Intermediate, Advanced, Black Belt
ADULTS
18-34 yrs old
Beginners, Intermediate, Advanced, Black Belt
SENIORS
35 and over
Beginners, Intermediate, Advanced, Black Belt
Super Pee Wee to juniors: Wood Only
Adults Only: can use Concrete or Wood (no
combinations)
Note:
Males and female will compete separately in ALL EVENTS. Accept Super Pee Wee to 12 yrs old, Kata & Self-defense
only. Divisions must have at least FIVE competitors or they will be combined
with other divisions. The promoters have the right to change divisions at the
time of the event.
BIGINNERS:
WHITE, YELLOW AND ORANGE BELT
INTERMEDIATE:
BLUE, PURPLE AND GREEN BELT
ADVANCED:
RED AND BROWN BELTS
