M.A.C. TRI-STATE NATIONAL CHAMPIONSHIPS

M.A.C. - Tri-State / 1 Year - Membership Application      M.A.C.- I.D. # :_________________

FIRST NAME:_________________    MIDDLE INT:_____    LAST NAME:___________________

AGE: ___   BELT RANK:_______   PHONE # : ( ___ ) ____ - __________   JACKET SIZE:_____

Address:______________________________     City:____________    State:____    Zip:_____

E-Mail Address:_____________________     Instr. Name:________________    Rank:_______

I WILL COMPETE THIS YEAR, IN THE FOLLOWING - COMPETITION DIVISION

(   ) MALE     (   ) FEMALE     HEIGHT: = ____ FEET      ____INCHES     WEIGHT: =_____ Lbs

I WILL COMPETE THIS YEAR, IN THE FOLLOWING - AGE DIVISION

AGE: (   ) 5 & Under,    (   ) 6-7,    (   ) 8-9,    (   ) 10-11,    (   ) 12-13,    (   ) 14-15,    (   ) 16-17,

(   ) Adult,- 18yr & Up      (   ) Adult- SR.,- 35yr & Up      (   ) Adult - EXEC.,- 45ys & Up 

(   ) MASTERS = 45yr & Up - 3rd Dan / Degree & Up

(   ) GRANDMASTERS = 55yr & Up - 6th Dan / Degree & Up

I WILL COMPETE THIS YEAR, IN THE FOLLOWING - BELT DIVISION

My Belt Color Is :______________           My Black Belt/Sash Rank Is:________ Dan / Degree

MY MEDICAL INFORMATION

(   ) I HAVE NO MEDICAL PROBLEMS

IF NOT CHECKED ABOVE, PLEASE INDICATE ANY MEDICAL PROBLEMS BELOW:

(   ) HEART MURMUR        (   ) CONCUSSION          (   ) SEIZURES                        

(   ) BONE FRACTURE      (   ) DIABETES                 (   ) ASTHMA                           

(   ) EYE INJURY                (   ) BONE BRUISING      (   ) HYPERTENSION       

(   ) BLOOD 

(   ) OTHER :_______________________________________________________________

BY SIGNING BELOW, I AGREE WITH AND STATE THAT, I HAVE READ THE REGISTRATION PROCEDURE, LISTED ON THIS U.S.M.A.N.com ON-LINE M.A.C.- TRI-STATE MEMBERSHIP FORM AND I UNDERSTAND THAT THE ACCURACY, LEGIBILITY AND TIMELY RETURN OF THIS APPLICATION IS IMPERATIVE FOR MY PARTICIPATION IN EVENTS, AND POINTS TOWARDS CHAMPIONSHIPS.

REMEMBER TO SIGN BELOW AND MAIL IT IN !!

I, hereby for myself, my executor(s) and heirs, forever and always agree to save and hold harmless the U.S.M.A.N..com, N.K.K.U., W.O.C., N.M.A.L., M.A.C., T.U.M.A.A., M.A.A.D., F.E.I., it's Organization(s), officers, referees, judges, volunteers, members, event directors, promoters, competitors, facility owners, their respective agents, successors or anyone else involved in these events. For any injury and/or liability, that I may sustain, to include my way of travel to or travel to or from the Martial Arts Events. My direct involvement participating in this event. I willingly, with full understanding, that I agree to allow, without compensation, the unrestricted use of any Website photographs, films or videotape of myself.

EMERGENCY # : (  ____  )   ____  -  ______    EMERGENCY PERSON : __________________

COMPETITOR SIGNATURE : _______________________________          DATE : __________

PARENT OR GUARDIAN SIGNATURE : ___________________________      DATE : ________

                                                                      ( If Competitor Is under 18yr Of Age )

MEMBERSHIP FEE : YOUTH = $30___   ADULTS = $35___   ALL BLACK BELTS = $40___

U.S. N.K.K.U. - N.M.A.L. - M.A.C. RULE BOOK ( IF NEEDED ONLY ) : $25.00 x ___ = Qty $____

MONEY ORDER # ___________________               TOTAL AMOUNT = $____________

                              RETURN TO :        ( M.A.C. )

                     c/o M.A.C.  TRI - STATE MEMBERSHIPS

              P.O. BOX 18393       GARDEN CITY, GA.   31408

Form :RF111458-99-03-07-11-m.a.c.-membership-form-online

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