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October 7, 2017, AIKC Rochester NY Online Registration
Please fill in this form as completely and as accurately as possible. Please mail in PAYMENT AND WAIVER FORM to complete registration.
First Name
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Last Name
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Middle Initial
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Date of Birth
MM
/
DD
/
YYYY
Age
Enter age on October 7, 2017
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Gender
Height
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Weight
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Street address
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City
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State/Province
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email address
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Dojo/School
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Martial Arts Style
example: Kyokushin Karate
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Instructor
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Instructor/Dojo Phone Number:
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Rank(kyu)
Either enter kyu or belt color.
Your answer
Rank(Dan)
Your answer
Years of Experience
Events
Tournament Director reserves the right to combine or further divide divisions based on registration.
Clicker
May only register for one(1) fighting event. (Clicker or Semi-Contact)
Required
Semi-Contact
May only register for one(1) fighting event. (Clicker or Semi-Contact)
Required
Kata
Required
Weapons Kata
Required
Creative Breaking
Required
Knock Down
(Please Complete Separate Application and Waiver)
Required
Payment and Waiver
One event is $45 and $10 for each additional event
**add $10.00 after September 30th, 2017***
All entry fees are non refundable.

Please Print and Mail the Waiver and Payment form. Groups of forms may be collected by Instructor and submitted as a single package. (http://www.graywolfmartialarts.com/files/2017_Waiver_and_Payment_Form.pdf)

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