Name: _________________________________________Belt_________ Age______ Sex_____ 
          First                             MI                           Last

Address: ________________________________________________Phone(       )______________
             Street                                 City                             State        Zip

Country Address: ________________________________________________________________

Martial Arts School Name: ________________________________E-Mail____________________

Complete Address: ___________________________________Phone(       )_______________
                           Street                   City                         State        Zip

Instructor's Name: ___________________________Rank______________ Style_____________

Number of division participating in ____division code numbers (     ) (     ) (     ) (     ) (     ) (     ) (     ) (     )

Pre-Registration must be sent and Paid to the order of: FEUDAL COMBAT
                                                                           228 N. CARONDELET STREET
                                                                           LOS ANGELES, CALIFORNIA 90026-5204

Registration payment should be in the form of money order or cashier check, no personal checks please. Registration at the day of the tournament must be in cash only.

Black belts registration fee:         $100.00------Includes all events. Day of the event registration: $125.00

Colored belts registration fee:     $55.00-------Includes all events. Day of the event registration: $75.00

Prospective participant must read and sign the liability waiver as required by the organizers of this tournament before being allowed and accepted to participate in this event. Signing this liability waiver will mean surrendering and waiving your right to sue for damages and claims in the event you or your child is fatally or mortally injured in this event.

I/We (Parents/Guardians)______________________________ the undersign acknowledge and knowingly without Duress do hereby voluntarily submit myself/my child's entry to the World Open Martial Arts Battle of Champions, which is promoted and hosted by ARCHANGELO P. FERNANDO of the WORLD SIMATUKIN UNION. I fully and knowingly acknowledge that, participating in this competition, will be physical and may result or cause my child's personal or physical disabilities, losses, injuries, paralysis or even death. Being fully aware of the risk of injuries losses, damages, disabilities, paralysis or death that I or my child may sustain during or after the tournament event, therefore I do hereby expressly assumes all risk of personal or physical disabilities, losses, injuries and death that I/my child may sustain during the course of my/my child's participation to this tournament event. With my competent sense and knowledge, I do hereby declare to release and waive claims and lawsuit against ARCHANGELO P. FERNANDO, the WORLD SIMATUKIN UNION, the SPONSORS of this event, ALL PERSONNEL'S, ALL OFFICIALS, AGENTS, EMPLOYEES, the LOS ANGELES SPORTS ARENA FACILITY, IT'S OWNERS, EMPLOYEES, SPECTATORS and all the PARTIES INVOLVED in this event from all liabilities and claims related to any personal or physical disabilities, injuries, damages, losses, paralysis and even death that I/My child may sustain during or after the tournament event. I do hereby declare with the very best of my ability, knowledge and competent senses my voluntary decision to assume full responsibilities for all related expenses pertaining to the above mention damages or losses such as injuries, paralysis and death that I/My child may sustain during and after the tournament event whether the said injuries, death, disabilities, damages and losses are caused by negligence or otherwise. In consideration for my participation or allowing my child to compete in this tournament, I/We (Parents/Guardians) do hereby release and waive all claims and lawsuits against these entities or persons such as ARCHANGELO P. FERNANDO, WORLD SIMATUKIN UNION, OFFICERS of the ORGANIZATION, OFFICIALS of the TOURNAMENT, TOURNAMENT SPONSORS, AGENTS, EMPLOYEES, ALL PERSONNEL'S INVOLVED IN THE TOURNAMENT, LOS ANGELES SPORTS ARENA FACILITY, its OWNER, EMPLOYEES, SPECTATORS and ALL PARTIES INVOLVED in the conduction of the tournament from all forms of personal or physical disabilities, injuries, damages, losses and death that I/My child may sustain in participation to this tournament competition or during and after the event. I am fully aware of myself/my child's personal and physical medical condition and do hereby declare and certify that I am/my child is mentally and physically fit to compete in this tournament. I further agree that any picture or video record coverage taken of me/my child in connection with this EVENT can be used by the sports organization of the WORLD SIMATUKIN UNION for publicity, promotions and sales and I fully waive my rights and claims for any compensation thereof. I have read the above contents of the agreement and fully understand what I have read and do hereby declare and agree to abide by the promulgated tournament rules and regulations and personally declares this agreement document legal, concrete, authentic and binding signed this ____day of________  2003.

 

By:_____________________________________   _____________________________________
                        Please sign here                                                                     Witness

     ______________________________________  _____________________________________
                         Printed Name                                                                    Printed Name