BELLIARE WUSHU ACADEMY CHAMPIONSHIP WHERE: BELLAIRE FITNESS CENTER 4330 PANTHER DRIVE BOSSIER CITY, LA 71112 WHEN: APRIL 23, 2016 8 A.M-12 P.M. EVENTS: BASIC MOVEMENTS, OPEN HAND FORMS, WEAPONS FORMS, FLAG SPARRING AND POINT SPARRING FOR AGES 13 AND UNDER EVENT FEES: $30 FOR TWO EVENTS $5 FOR ANY ADDITIONAL EVENTS SPECTATOR FEES $2 A PERSON CHILDREN UNDER THREE ARE FREE PRE-REGISTER BY: APRIL 15, 2016 Please fill out legibly and mail your form, along with your payment, to the address below: Bellaire Wushu Academy 4330 Panther Drive Bossier City, LA 71112 Accepted payment types for pre-registration are check, money order and credit/debit card If paying by credit or debit card, mail in your pre-registration information along with your credit/debit card information, or you may call Bellaire Wushu Academy at 318.470.1307 over the phone. FOR A SCHEDULE GO TO www.bellairewushuacademy.org

BELLIARE WUSHU ACADEMY CHAMPIONSHIP

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BELLIAREWUSHUACADEMYCHAMPIONSHIP

WHERE:BELLAIREFITNESSCENTER4330PANTHERDRIVEBOSSIERCITY,LA71112

WHEN:APRIL23,20168A.M-12P.M.

EVENTS:BASICMOVEMENTS,OPENHANDFORMS,WEAPONSFORMS,FLAG

SPARRINGANDPOINTSPARRING

FORAGES13ANDUNDER

EVENTFEES:$30FORTWOEVENTS

$5FORANYADDITIONALEVENTS

SPECTATORFEES$2APERSON

CHILDRENUNDERTHREEAREFREE

PRE-REGISTERBY:APRIL15,2016

Pleasefilloutlegiblyandmailyourform,alongwithyourpayment,totheaddressbelow:

BellaireWushuAcademy4330PantherDriveBossierCity,LA71112

Acceptedpaymenttypesforpre-registrationarecheck,moneyorderandcredit/debitcardIfpayingbycreditordebitcard,mailinyourpre-registrationinformationalongwithyourcredit/debitcardinformation,oryoumaycallBellaireWushuAcademyat318.470.1307

overthephone.

FORASCHEDULEGOTOwww.bellairewushuacademy.org

Page 2: BELLIARE WUSHU ACADEMY CHAMPIONSHIP

BellaireMaritalArtsChampionshipPre-RegistrationForm

Name__________________________________________________________________________________________________________

Address_______________________________________________________________________________________________________

City_____________________________________________________State____________________Zip_______________________

Telephone___________________________________________Or_____________________________________________________

Age_______________EmailAddress___________________________________________________________________________

Style____________________________________________________________Rank________________________________________

Instructor_______________________________________________InstructorsRank________________________________

SchoolName__________________________________________________________________________________________________

SchoolAddress________________________________________________SchoolPhone______________________________

City_____________________________________________________State______________________Zip______________________

Pleasechecktheeventsthatyouwillbecompetingin:☐Openhandforms☐Weaponsforms☐BasicMovements(3-5years)☐Pointsparring☐Flagsparring(3-5years) T-shirtsize(ForPre-registrantsonly):�YouthSmall� YouthMedium�YouthLarge� AdultSmall� AdultMedium� AdultLarge� AdultExtraLarge�Adult2XLRegulationMartialArtsUniform,HandPads,FootPads,Headgear,Mouthpiece,andGroinProtectorformalesarerequiredinalldivisions.Ihaveread,Iunderstand,andIagreetoabidebyalltherulesandregulationssetforthforthistournament.IunderstandthatthereisariskofpersonalinjuryinvolvedinthistournamentandwiththisknowledgeIagreetotakefullresponsibilityforanyofmyactions,andIagreetoindemnify,saveandholdharmlessBellaireWushuAcademy,itsstaff,instructorsandassistants,BellaireFitnessCenterandBellaireBaptistChurchandanyofitsstafforcomponentsfromanyandalllosesorclaimscausesbyaccidentorinjurytomeortoanythirdpersonswhomaybecompetitorsoraffiliatedwithandofthepreviouslynamedentitiesinanymanner,intheeventthatmyselforsaidthirdpersonisinjuredinanywayinthisevent.BecauseofthephysicaldemandsofMartialArtstournamentcompetition,IunderstandthatImustbeingoodphysicalconditionandthatIdonothaveamedicalconditionthatmayposearisktomyselfortoanyothercompetitorsduringthecourseofthisevent.Ifunder18yearsofage,thisreleaseandconsentmustalsobesignedbyaparentorguardian.______________________Date______________________________________________________________________________________________________SIGNATUREOFCOMPETITOR SIGNATUREOFPARENT/GUARDIAN