KICKWRESTLING ALLIANCE

KWA Tournament Registration

Name______________________________

Address___________________________

City______________ State__________

Country_______________

Date of Birth_________

Home Phone (____)____-____ E-mail (if any)______________________

Name of Parent or Guardian
(if under 18)_________________________

Weight Classes

Light-149 or less ____ Middle- 150-169 ____ L. Heavy 170-189 ____ Heavy 190 and over____


Backround Information

School Name__________________________________

Instructor name(s)___________________________

School Phone (___)___-____

Style(s) _____________________________________

Beginner__ Intermediate__ Advanced__

(6 months or less) (6 months- 2 year) (More than 3 years)

(check one only)

Event you will be competing in:

KICKWRESTLING_____ SPORT GRAPPLING______
(check all the apply)

Have you had any previous injuries? ____Yes No____

If yes, please explain:
_______________________________________________________

_______________________________________________________

Do you have current and valid health insurance?____ Yes No____
Insurance Company______________________________________

Please list (if any) current or past health problems and/or serious injuries.
None____

_______________________________________________________________

_______________________________________________________________

In case of emergency please, contact :

Name:_______________________________

Relationship:_______________________

Phone Number: (___)___:____

Release and Waiver

I, the undersigned hereby waive all claims against any and all persons associated with any of the participating schools, associations and competitors. I understand the rules of the Tournament and will abide by them. I understand that I am participating in a sport which has body contact. I assume full responsibility for all my actions during and connected to the above tournament. I understand the risk of competing in this form of Martial Arts competition and hereby release Gold Medal Fitness, Juan Rio and all of its agents, employees and associates, Basic Instinct Street Defense, Kickwrestling Alliance, KWA Tournament, Sport Combat Championship tournament sponsors, Richard Failla, and all of his agents,Judges employees and associates, of and from any and all liability, claims, demands, actions, medical bills, and causes of action whatsoever arising out of or relating to any negligent or other act or omission, and /or any loss damage or injury, including death, that may be sustained by the undersigned or any property of the undersigned in participating in this competition. I, the undersigned also state that I am in good physical condition and know of no reason why I can not compete in this tournament. Divisions and weight classes are subject to change. I understand that in case of emergency, I hereby authorize any licensed medical personnel to perform any accepted medical assistance deemed necessary and I agree to bear the expense of any such treatment. I also agree that my attendance and/or performance at the tournament may be photographed, filmed or taped and used in schools and/or by the Kickwrestling Alliance, I authorize the use of my image and I waive any compensation thereof. I, the undersigned, being duly aware of the risks and hazards inherent upon participating in the Sport Combat Championships agree to all its rules, terms and conditions. In signing the foregoing release, the undersigned hereby acknowledges and represents: that he/she has read the foregoing release, understands it and signs it voluntarily; that he/she is over 18 years of age and of sound mind. If under 18, parent/legal guardian in signing this release agrees to all its terms and conditions.


Signed: _________________________________

Parent or Legal Guardian: _____________________
(if under 18 years of age)

Print Name: _____________________________

Date: _________________

Pre-Registration Fee Fee: $ 35.00 (for one event) $10.00 addtl.event
Fight Card Fighters $30.00
After March 25,2000
One event $45.00 Addtl. $15.00

Please send Pre registrations to:
GOLD MEDAL FITNESS c/o

Richard Failla
18647 SW 107 Ave.
Miami, Fl 33157