Weight Classes Release and Waiver Pre-Registration Fee
Fee: $ 35.00 (for one event) $10.00 addtl.event
Please send Pre registrations to:
NOVEMBER 2000
Gold Medal Fitness
18647 SW 107 Ave
Miami Florida 33176
Name______________________________
Address___________________________
City______________ State__________
Country_______________
Date of Birth_________
Home Phone (____)____-____ E-mail (if any)______________________
Name of Parent or Guardian
(if under 18)_________________________
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: (___)___:____
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: _________________
Fight Card Fighters $30.00
After March 25,2000
One event $45.00 Addtl. $15.00
GOLD MEDAL FITNESS c/o
Richard Failla
18647 SW 107 Ave.
Miami, Fl 33157