2 PERSON TEAM KATA/FORMS - COMPETITOR APPLICATION 

(     PLEASE PRINT     TEAM NAME:____________________________________     ) 

WE WILL PARTICIPATE IN :   TEAM KATA / FORMS  -  FEMALE  and/or  MALE

AGE GROUP All Belts : (   ) 3 - 5yr  (   ) 6 - 9yr   (   ) 10 - 13yr   (   ) 14 - 17yr

                        (   ) ADULTS under belts,   (   ) ADULT BLACK BELTS                   

(   2 PERSON  (  MALE and/or FEMALE  )  TEAM KATA / FORMS   ) 

YOUTH TEAMS UNDER 18yrs     ADULT TEAMS 18yrs & Up      ADULT TEAMS BLACK BELT

WHITE up to BLACK BELT       WHITE up to BROWN BELT               BLACK BELT     

 ************************************

(  COMPETITOR # 1  )                                                                                                                                                                                                    LAST NAME:__________________  FIRST NAME:__________________  MIDDLE INT:____ ___________________________________________________________________________ STREET .................................CITY .................................STATE..................... ZIP

(  ) MALE .....(  ) FEMALE.............. (  )   I HAVE NO MEDICAL PROBLEMS

                                             COMPETITOR #1 MEDICAL INFORMATION   

  MEDICAL PROBLEMS:                                                                                                              

IF YOU HAVE INDICATED ANY MEDICAL DISORDERS YOU MUST ATTACH A DOCTOR’S RELEASE FORM STATING YOU ARE ABLE TO COMPETE. 

COMPETITOR SIGNATURE:                                                                           DATE:                       

************************************ 

(  COMPETITOR # 2  )                                                                                                                                                                                                    LAST NAME:__________________  FIRST NAME:__________________  MIDDLE INT:____

 ___________________________________________________________________________ STREET .................................CITY .................................STATE..................... ZIP

(  ) MALE .....(  ) FEMALE.............. (  )   I HAVE NO MEDICAL PROBLEMS

COMPETITOR #2 MEDICAL INFORMATION 

MEDICAL PROBLEMS:                                                                                                              

IF YOU HAVE INDICATED ANY MEDICAL DISORDERS YOU MUST ATTACH A DOCTOR’S RELEASE FORM STATING YOU ARE ABLE TO COMPETE. 

COMPETITOR SIGNATURE:                                                                           DATE:                       

************************************

BY SIGNING ABOVE & BELOW, I/WE AGREE WITH AND STATE THAT, I/WE HAVE READ THE REGISTRATION PROCEDURE LISTED IN THIS FORM AND I/WE UNDERSTAND THAT THE ACCURACY, LEGIBILITY AND TIMELY RETURN OF THIS APPLICATION IS IMPERATIVE FOR MY PARTICIPATION IN THIS EVENT.

REMEMBER TO SIGN BELOW AND MAIL IT IN !! 

I/We, hereby for our/myself, our/my executor(s) and heirs, forever and always agree to save and hold harmless the N.K.K.U., 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/We may sustain, to include my way of travel to or from the Olympia Games, My direct or indirect involvement participating in this event. I/We willingly, with full understanding, that I/We agreed to enter and participate in this contact sport at my own risk. Therefore I’m responsible for my own injury insurance, and I agree to allow, without compensation, the unrestricted use of any photographs, films or videotapes of our/myself.

GUARDIAN SIGNATURE:                                                                            DATE:                         

 ( GUARDIAN SIGNATURE NEEDED IF COMPETITORS ARE UNDER 18 YEARS OF AGE )

 ( 2 Person Team Registration Fee = $20 )    MONEY ORDER # _________________

Only Cash Will Be Accepted at the Competition Door !!!       PAID AMOUNT $____________

              RETURN TO :              ( N.K.K.U. ) 

                                         c/o OLYMPIA GAMES 

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

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