NE GRAPPLING CHALLENGE VII
Saturday May 30, 2009
BridgewaterState College
Bridgewater, MA02325
Name: _______________________________________________
Phone: ____________________
Address: ________________________________________________________________________
City: _______________________________________
State: ____________
Zip: ______________
E-Mail: ________________________________
Date Of Birth: __/__/__
Approx Weight: _______
Choose One Of The Following Divisions
___ Men Beginner: Less than 1 year of any grappling art
___ Men Intermediate: Up to 2 years of any grappling art
___ Men Advanced: More than 2 years of any grappling art
___ ABSOLUTE: $500 Cash Prize (can participate in absolute and one other division)
___ Masters: (30+ years broken down by weight)
___ Women: (broken down age/weight)
___ Children: (9-14 broken down by age/weight)
___ Teen: (15-17 broken down by age/weight)
School Name: ____________________________________
Instructor: ______________________
School Address: _______________________________________
School Phone: ______________
Emergency Contact Name: ___________________________________
Emergency Phone: ________________
TOURNAMENT RELEASE AND WAIVER (please read before signing):
I, (print name) _______________________________________ the undersigned, hereby waive all claims against Ryan Ciotoli, Rick Caldwell, Bridgewater State College, and any and all other persons associated with this event in any capacity from any and all liability due to injuries that I may incur as a result of my attendance and/or participation at this event. I understand the rules of the tournament and will abide by them. I understand that I am participating in a sport that has body contact. I assume full responsibility for all of 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 the event organizers and all of its employees and associates, tournament sponsors, and the event facility, from any type of injury, loss, or death sustained while competing in this competition. I also state that I am in good mental and physical condition and know of no reason why I cannot participate in this Martial Arts event. I have current and valid health insurance. Divisions or weight classes are subject to change. In case of an emergency, I hereby authorize any licensed medical personnel to perform any accepted medical procedure deemed necessary and I agree to bear the expense of any such treatment. I understand that a valid birth certificate may be required to compete at this event. I also agree that my attendance and/or performance at the tournament may be photographed, filmed, or taped and used by any schools and I waive any compensation thereof. I have read, understand and agree to abide by the rules associated with this event and assume all responsibility and any associated liability for infringement of such rules and sign below to complete this form:
Signed: _____________________________
Print Name: _____________________
Date: __/__/__
Parent or Guardian (if under 18): _______________________________________
Date: __/__/__
MAIL REGISTRATIONAND PAYMENT TO: Ryan Ciotoli 4710 Rt. 41 Cortland, NY13045
$50 pre-registration - prior to May 23, 2009
$60 at the door
