______________________________________

Name

______________________________________
Address

______________________________________

SUTHERLAND TKD KEMPO

Championship Tournament
October 22, 2016
sutherlandtkd@gmail.com
(402) 802-6038

______________________________________ Check all events entering:

Email
Board Breaking
______________________________________
Traditional Weapon
Phone
Age
Traditional Form
______________________________________
Point Sparring
Belt Rank
BEG [ ] INT [ ] ADV [ ] BLACK [ ]
Team Forms
______________________________________
School or Instructor

Send Payment to:

Sutherland TKD Kempo
301 Linden Street
Sutherland, NE 69165
$30 Pre-registration up to 2
events.
10% HMAL/Alliance/UKKS
member discount honored
$10 each additional event
$40 registration after Oct 14
NO discounts
$10 each additional event

Waiver Assumption of Risk

In consideration of your acceptance of my registration, I do hereby, for myself, my heirs, executors and administrators, waiver, release
and forever discharge any and all right and claims for damages which I may have or which may occur against Sutherland Taekwondo,
the Heartland Martial Arts League, the Alliance and Sutherland Public Schools, its instructors, landlords, representatives, agents and
fellow students; for any and all damages which may be sustained and suffered by me or any member of my family in connection with
my participation in this activity, including traveling to or from the event or injury during such event. I further understand, all reasonable
care will be taken by the instructors to see that an injury does not take place, but that Martial Arts is a body contact sport.

Event Location
Sutherland Public Schools North Gym
401 Walnut Street
Sutherland, NE 69165

_______________________________________________________
Signature of participant

Date

_______________________________________________________
Signature of parent or guardian if participant is under 19

Date

__________________________________________________________________________________________________________________________________________

______________________________________
Name

______________________________________
Address

______________________________________

SUTHERLAND TKD KEMPO

Championship Tournament
October 22, 2016
sutherlandtkd@gmail.com
(402) 802-6038

______________________________________ Check all events entering:

Email
Board Breaking
______________________________________
Traditional Weapon
Phone
Age
Traditional Form
______________________________________
Point Sparring
Belt Rank
BEG [ ] INT [ ] ADV [ ] BLACK [ ]
Team Forms
______________________________________
School or Instructor

Send Payment to:

Sutherland TKD Kempo
301 Linden Street
Sutherland, NE 69165
$30 Pre-registration up to 2
events.
10% HMAL/Alliance/UKKS
member discount honored
$10 each additional event
$40 registration after Oct 14
NO discounts
$10 each additional event

Waiver Assumption of Risk

In consideration of your acceptance of my registration, I do hereby, for myself, my heirs, executors and administrators, waiver, release
and forever discharge any and all right and claims for damages which I may have or which may occur against Sutherland Taekwondo,
the Heartland Martial Arts League, the Alliance and Sutherland Public Schools, its instructors, landlords, representatives, agents and
fellow students; for any and all damages which may be sustained and suffered by me or any member of my family in connection with
my participation in this activity, including traveling to or from the event or injury during such event. I further understand, all reasonable
care will be taken by the instructors to see that an injury does not take place, but that Martial Arts is a body contact sport.

Event Location
Sutherland Public Schools North Gym
401 Walnut Street
Sutherland, NE 69165

_______________________________________________________
Signature of participant

Date

_______________________________________________________
Signature of parent or guardian if participant is under 19

Date