Name: *

Rank: 10 Gup White Belt 9 Gup White/Yellow Belt 8 Gup Yellow Belt 7 Gup Orange Belt 6 Gup Light Green Belt 5 Gup Dark Green Belt 4 Gup Light Blue Belt 3 Gup Dark Blue Belt 2 Gup Red Belt 2 Gup Red/Brown Belt 1 Gup Brown Belt 1 Gup Brown/Black Belt 1 Dan Black Belt 2 Dan Black Belt 3 Dan Black Belt *

Club: Chanhassen Rec. Center Life Time Fitness Eden Prairie Life Time Fitness Chanhassen *

Age: *   Gender: Male Female *

Weight: *   Height: *Invalid format. (5ft. 2in = 5-02)

Event(s): Form     Sparring *

Home Address:

City: State: Zip:

Cell Phone:
Required in case of emergencyInvalid format.

Email: Invalid format.

By providing my electronic signature I hereby submit my application for registration in American Tae Kwon Do Championship competitions. I agree to waive claims against any persons, schools, associations connected with American Tae Kwon Do Championship for any injuries I may sustain and like wise assume full responsibility for all my actions in connection with said competitions.

I Further agree that any pictures taken of or by me in connection with said competition, can be used by the Tournament Director for publicity without compensation at this time or at any other time.

If under 18, a parent or legal guardian must also provide an electronic signature for this release and consent.

Competitor Signature *    Parent Signature