Florida State Judo Championships - Tomodachi Judo Club

1 Florida State judo ChampionshipsSponsored bythePalmBeachCountySports CommissionCongress MiddleSchool101 S. , Fl 33426 Saturday,April 16, 2016 Shiai Competition Start 10 APairings to be posted @ Venue:9A Saturday 4/16/16 Rules Meeting:9A Coaches welcomeEligibility:Current USJA, JF or JIDivisions:Standard USA JudoAges &WeightsYouthsborn after 1999 2 yr increments (Light, Med. Heavy)Rules:IJF (modified), No blue gi required, Double EliminationUSA judo Youth rules & times apply for Cadets & JuniorsMatches: 3 min.

2 Youths & Masters, 5 min. Seniors, 2 min. Ne WazaTournament director reserves the right to make changes as neededDownload Event Registration/Waiver $ byTuesday,4/12/16. Late fee is$ No Registrationswill be accepted after5PM Friday, 4/15/16!($40 for extradivisions)All competitors get a medal!Awards:1st, 2nd, 3rd,& Participation Medals1st, 2nd& 3rdPlace Overall Club TrophiesHotel:The Inn at Boynton Beach-480 West Boynton Blvd., Boynton Beach, Fl. 33445 Tel: (561) 734-9100 Fax: (561) 738-7193 Mention judo -Room Rates will be $85 per night plus Club Coaches!

3 Askabout club weigh-in & registration discountsInfo: Mike Szrejter-Voice/Fax: (561)-496-7000 or 738-7704 Cell (561) judo Event Official EntryFormCash$Check#Event NameEvent DateContestantLastName(please print!)FirstMIWeight(kg)MaleBelt color/ RankBirth DateAgeClub NameFemaleDivision to compete inShiaiNe Waza (Grappling)2nd DivisioinM a s t e r D i v i s i o n ( 3 0 yr s a n d o l d e r )S e n i o r D i v i s i o nY o u t h D i v i s i o n ( u n d e r1 7 yr s )Membership Information:USA JudoUSJA USJFO ther organization:Membership #:Expiration Date:Contestantmustprovideproofof currentmembership or copyofapplicationfornew/renewal ofmembership!

4 Personal Information:Street AddressEmailCityStateZipTelephoneParent/ Guardians Contact ..Inconsideration ofyouracceptanceofthisentry,Iherebyformy self,myheirs,executorsandadministrators, waiveandreleaseallrightsandclaimsfordama gesImayhaveagainsttheTomodachi JudoClubandallotherparticipants andthiseventsofficialsandemployees, representativesorassignees,includingUnit edStatesJudo,Inc.,USAJudo,UnitedStatesJu doFederationInc.,UnitedStatesJudoAssocia tionInc.,CityofBocaRaton&GreaterBocaRato nParkDistrict,CityofBoynton Beach,BoyntonBeachParksandRecreation,Cit yofDelrayBeach,DelrayBeachPoliceDepartme nt,CongressMiddleSchool,AtlanticHighScho olandPalmBeachCountySchoolBoardfordamage sorinjurieswhichmaybesufferedbymeasa resultofattending,participatingin, namedperson(s)toactinmybehalfinanyanallm attersrequiringparentalconsentformychild (contestantnamedaboveifunder18yearsofage )duringthe s Signature (minor and adult)

5 DateParent/Guardian s Signature(for contestants under 18 yearsold)DatePlease make checks payable to:TomodachiJudo2534SW12 Street,BoyntonBeach,Fl33426 Waiver on reverse side must alsobe completed!Entry form on reverseside mustalso be completed!WARNING!WAIVERANDRELEASEOF LIABILITYANDAGREEMENTTOPARTICIPATEI nconsiderationofbeingpermittedtoparticip ateinanyway,includingtraveltoandfromanyj udotournament,practice,clinic, andrelated eventsandactivities oftheUnitedStatesJudo,Inc.,USAJudo,Unite dStatesJudoFederationInc.,UnitedStatesJu doAssociationInc.

6 ,CongressMiddleSchool,Atlantic HighSchool,PalmBeachCountySchoolBoard,Ci tyofBocaRaton&GreaterBocaRatonParkDistri ct,CityofDelrayBeach,DelrayBeachPoliceDe partment,CityofBoyntonBeach,BoyntonBeach Parks&Recreation,FloridaJudoAssociation, andTomodachiJudoClub, Iamfamiliar priortoparticipating,Iwillinspectthemats ,equipment,facilities, competitionpoolsordivisionsandtheelimina tionorscoringsystemto beused,andifIbelieveanythingisunsafeorbe yondmycapability,I will immediatelyadvisemycoach,supervisor, understandthatIwillbe engagingin acontact sport thatmightresultinseriousinjury,including permanentdisabilityordeath,andseveresoci alandeconomiclossesduetonotonlymyownacti ons,in-actions,ornegligence,butalsotothe actions,in-actions,ornegligenceofothers, therulesofthesportofJudo, ,Iacknowledgethat theremaybeotherrisksnotknowntomeornotrea sonablyforeseeableat ,Iassumeall suchrisksandaccept personalresponsibilityforthedamagesfollo wingsuchinjury,permanentdisability, ,waive.

7 DischargeandcovenantnottosuetheUnitedSta tesJudo,Inc.,USAJudo,UnitedStatesJudoFed erationInc.,UnitedStatesJudoAssociationI nc.,CongressMiddle,Atlantic High,PalmBeachCountySchoolBoard,CityofBo caRaton&GreaterBocaRatonParkDistrict,Cit yofDelrayBeach,DelrayBeachPoliceDepartme nt,CityofBoyntonBeach,BoyntonBeachParks& Recreation,FloridaJudoAssociation,andTom odachiJudoClub,togetherwiththeiraffiliat ed clubs,theirrespectiveadministrators,dire ctors,agents,coachesandotheremployeesorv olunteersoftheorganization,eventofficial s,medicalpersonnel,otherparticipants,the irparents,guardians,supervisorsandcoache s,sponsoringagencies,sponsors,advertiser s.

8 Andifapplicable,owners,lessors,andlessee sofpremisesusedtoconducttheevent,all ofwhomarehereinafterreferredtoas"Release e",fromanyandall claims,demands,losses,ordamagesonaccount ofinjury,includingpermanentdisabilityand deathanddamagetoproperty,causedoralleged tobecausedinwholeorinpartby thenegligenceoftheReleasee orotherwisetothefullestextentpermittedby HAVEREADTHEABOVEWARNING,WAIVER AND RELEASE, UNDERSTANDTHAT I GIVEUPSUBSTANTIAL RIGHTS BY SIGNINGIT,ANDKNOWINGTHIS, SIGN IT VOLUNTARILY. I AGREETO PARTICIPATE KNOWING THE RISK AND CONDITIONS INVOLVED AND DOSO ,OR,IFIAMUNDER18 YEARSOFAGE,IHAVEOBTAINEDTHEREQUIREDCONSE NTOFMYPARENT/GUARDIANASEVIDENCED BY THEIR 's Printed NameParticipant sSignatureDateFORPARENTS/GUARDIANS OF PARTICIPANTS OF MINORITY AGE(UNDER AGE 18 ATTIMEOF REGISTRATION)

9 ThisistocertifythatI,asparent/guardianwi thlegal responsibilityforthisparticipant,doconse ntandagreetohis/herrelease,asprovidedabo ve,ofalltheReleasees, and,formyself,myheirs, assigns,andnextofkin,Ireleaseand agreetoindemnifyandholdharmlesstheReleas eesfromanyandallliabilitiesincidenttomym inorchild'sinvolvementorparticipationint heseprogramsasprovidedabove,evenifarisin gfromtheirnegligence, theminorparticipantastotheabovewarningsa ndconditions and their s Printed NameParent/Guardian sSignatureTomodachi judo ClubCreditCardChargeRequestIfyou wish to use yourCredit Cardfor a Payment or Donation to Tomodachi ,please completethe followinginformationand enclose withyourapplication form(s):Name:Address:Billing Zip Code Needed:Telephone#:Credit Card (circle one).

10 MasterCard----VISA----Discover----Americ an ExpressCreditCard#\\\CreditCardExpiratio nCVVCode(Month)(Year)Nameasit appearsonCreditCard(pleaseprint):Amount: $5%handlingfee:$Amountauthorizedtocharge :$Signature:Date:_Memo: Tomodachi judo