2021 VA AAU Regional Championship

Participant Contact Information

Athlete Name

Parent or Guardian

Phone Number

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Address

Registration Information

2021 AAU #

Dojo

Sensei Name

Gender

Male
Female

Date of Birth

Age (as of July 01, 2021)

Age/Division

Weight (lbs.)

Experience

Choose one

I will compete in the following

Mandatory (Adv belts ages 16 and up ONLY)

Kobudo Long/Short Combined (All levels)

PeeWee (age 4)

Kata

Kumite

Rotational Kumite

Combined genders will be put with Male division

Special Talents/Special Needs

Coach

Medical Information

Fee(s)

Early Bird Registration: Received by May 21, 2021 - $75

Regular Registration: Received May 22-28, 2021- $85

On-site Registration - $100

Pee Wee Registration - Ages 4 and under ONLY $10

Rotational Kumite - $30

Coach - (no fee, must have 2021 AAU #)

Registration

Total

$0.00

Waiver

Parent or Guardian if under 18yrs. of age

I here by for myself, my executor(s), my heirs, forever and always agree to save and hold harmless the Amateur Athletic Union of the United States
and all of its officers, referees, judges, volunteers, workers, members, tournament director, tournament promoter, tournament employees, the facility
owners, their Respective officers, participating in, or other direct or indirect involvement in the AAU/USA karate Tournament that I have entered. In
addition, I hereby for now and forever, accept any and all responsibilities for any actions in conjunction with the AAU/USA Karate Tournament and
the traveling to or from or participating in said event. Finally, I agree to allow, without compensation, the use of any photographs, films, or videotape
of myself

I have read and agree to the terms above.