2017 Gold Mountain Invitation Youth Karate Tournament Registration Form 2017 Gold Mountain Invitation Youth Karate Tournament Registration Form First Name * Last Name * Age * 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Rank * White Belt Yellow Belt Orange Belt Purple Belt Blue Belt Green Belt Brown Belt Black Belt Address * City * Dropdown * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code * Dropdown * Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Colombia Comoros Congo Costa Rica Côte d‘Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland France French Guiana French Polynesia Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Zealand Nicaragua Niger Nigeria Norway Northern Mariana Islands Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Sudan Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Yemen Zambia Zimbabwe Phone Number * Email Address * Would you like to sign up for our newsletter? 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Studio Name * Instructor * Type of Martial Art * Years in the Art * Sex * Male Female Individual Events * Traditional Kata Weapons Point Sparring Synchronized Kata Synchronized kata can be 2 or 3 competitors I Agree to the terms and Agreements * RELEASE AND WAIVER OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT In consideration of being permitted to participate in this event, the undersigned, for himself/herself, he/her personal representatives, assigns, heirs, and next of kin: Hereby releases, waives, discharges, and covenants not to sue the Gold Mountain Invitational Youth Karate Tournament, its promoters, sponsors, participants, officials, rescue personnel, advertisers, landowners, lessees, and permitees of the premises used to conduct the even, and each of them, and their respective directors, officers, agents, and employees, and all others whether listed herein by name or category or neither, all for the purpose herein referred to as “Releasees”, from all liability to the undersigned, his personal representative, assigns, heirs, and next of kin, for any and all loss or damage, and nay claim or demands, therefore, on account of injury to the person or property or resulting death of the undersigned, arising of or related to the undersigned’s participation in the event, whether causes by the negligence of the Releasees or otherwise. Hereby acknowledges that there is the risk of serious injury and/or death and/or property damage from participating in the event. Each of the undersigned also expressly acknowledges that injuries received may be compounded or increased by negligent rescue operations or procedures of the Releasees, all of which are released and waived. In connection with my participation in The Gold Mountain Invitational Youth Karate Tournament, I consent to the use of my photograph and video or other likeness in the promotional and other materials of The Gold Mountain Invitational Youth Karate Tournament without payment or other consideration made to me. In addition, I agree to pay the tournament fee of $35.00.