Registration
Please pre-register for this event using the form below:

Last Name	*
First Name	*
Middle Initial	*
E-mail (pdf will be sent here-please print and bring to event)	*
Age	*
Date of Birth	*
Gender	*	Male Female
ATA #	*
Current Rank	*
Judging Level (Black Belt Only)
Phone	*
Home Address	*
City	*
State	*	- - Choose One - - Alabama Alaska Arizona Arkansas California Colorado Connecticut D.C. Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip	*
Instructor's Name	*
School Address	*
School Number	*
Region
Forms & Sparring (one event whether doing one or both)	*	Tiny Tiger Special Ability Junior 6-7 Junior 8-10 Junior 11-13 Junior 14-16 Adult 17-29 Adult 30-39 Adult 40-49 Adult 50-59 Adult 60 & Up
Rank Competing As	*	White Orange Yellow Camo Green Purple Blue Brown Red Red/ Rec Black / 1st Black / 2nd Black / 3rd Black / 4th Black / 5th
Competition Events	*	Forms & Sparring Protech Weapons Xtreme Forms Xtreme Weapons
Number of Events		$35 Forms Sparring $60 Forms Sparring (Weapons or One Extreme) $85 Forms Sparring (Weapons and 1 Extreme) $95 All 5 Events $5 3rd Family Member Forms Sparring $10 3rd Family Member Forms Sparring (W or 1 E) $15 3rd Family Member Forms Sparring (W & 1 E) $20 3rd Family Member All 5 events Test Event 1
Additional Family Members Attending
Date	*
Athlete Signature (enter name)	*
Contestants under age 18 require parent/legal guardian signature
Submitted by		Instructor Competitor/ Participant