GREAT WESTERN NATIONALS INDIVIDUAL & TEAM ENTRY APPLICATION
INSTRUCTIONS: Please read all information carefully. Must print legibly. Waiver of injury must be signed. All events must be correctly entered. Failure to complete all instructions will result in an unprocessed application. Fill in the Registration Form, submit it, then print and mail a copy with your check or money order made payable to "GREAT WESTERN NATIONALS, P.O. Box 1536, Carson City NV 89702". For pre-registered your registration must be postmarked by June 22, 2005. Pre-Registration Fees: 1st Event $30.00, all other events $10.00 each. At the Door Fees: 1st event $35.00 all other events $15.00 each.

INDIVIDUAL APPLICATION
Please print clearly. Each Team Member must fill out a separate application

Competitor's Last Name  First Name 

Birthday  Age    Gender  M F Weight  Belt Color

Competitor's T-Shirt Size (Adult S, M, L, XL, 2X, 3X YOUTH S, M, L)

Competitor's Address City

State   Zip   Phone:

Competitor's Email

School Name

School Address

City State   Zip   Phone: FAX:

School Email:   Instructor's Name 

Check ratings you follow: WSKFNASKAUSKAPacific Rim TourEKLSMACOther

TEAM APPLICATION
Team registration must be submitted on one application. Team forms must have one black belt. Event code and signature is mandatory and acknowledges that individual has read and understands waiver, and thereby agrees to take responsibility.

Last Name  First Name 

Birthday  Age    Gender  M F Weight  Belt Color 

Applicant/Parent Signature 

Last Name  First Name 

Birthday  Age    Gender  M F Weight  Belt Color 

Applicant/Parent Signature 

Last Name  First Name 

Birthday  Age    Gender  M F Weight  Belt Color 

Applicant/Parent Signature 

Team Name  Team Coach 

REGISTRATION INFO
NO ONE WILL RECEIVE UNATTACHED WRISTBANDS

ABSOLUTELY NO REFUNDS FOR MISSED EVENTS, DISQUALIFICATION OR INJURY!
Pre-Registration Fees: 1st event $30.00, all other events $10.00 each.
T-Shirts $16.00 (Adult  S, M, L, XL, 2X, 3X Youth S, M, L)
At the Door Fees: 1st event $35.00 all other events $15.00 each. NO PERSONAL CHECKS.
Pre-register online between April 15 and June 27, 2005 or mail your completed application to GREAT WESTERN NATIONALS, P.O. BOX 1536, CARSON CITY, NV 89702 so it is postmarked no later than June 22, 2005. Contestants who are unable to pre-register may register at the tournament. Money orders and cashiers checks, must be made payable to GREAT WESTERN NATIONALS, or cash is accepted. General Admission: Adults $10.00, Children 5-13 $5.00, under 5 Free.

We reserve the right to refuse admittance or revoke the purchased entry or pass of any Competitor, Spectator, Coach, Judge, or other persons entering the tournament, if we deem they have been or are in violation of the essence of the Martial Arts and the competitions held herein. WSKF fines will be strictly levied towards those who do not behave in the proper manner. Please help us to keep this sport a fun and rewarding experience for all attendees by exhibiting respect and honor toward one another. We are the examples our children will follow in the future. Please keep this in mind and go through the proper channels and exhibit the correct behavior when lodging any complaint.

I, the undersigned, hereby release the Great Western Nationals, USADOJO.COM, Chili Bop Entertainment Group, WSKF, Dana L. Stamos, Ken and Barbie Dickinson, Steve Cooper, the event sponsors, volunteers & staff, Northern Nevada Alliance of Martial Artists, American Teachers Association of the Martial Arts, tournament promoters and any and all other persons associated with this event in any capacity, from any and all liability due to injuries up to and including death that I may sustain or incur as a result of my attendance, travel to or from, and/or participation in any Great Western Nationals event. Furthermore, I hereby waive any compensation whatsoever for the use of pictures, video or film production of myself, utilized by those associated with this event, for any profit-making at any time now and in the future. I understand that I am entirely responsible for obtaining permission from the artist(s) for any music I use for my competition or otherwise, and verify by the signing of this, that I have done such. I agree to indemnify, defend and hold blameless all of the above named parties abd persons from any liability or compensation for use of such music and further state that the above named parties and persons may use such music in any recorded performances of myself for profit making purposes, at any time. I clearly understand that the sparring aspect of this sport and competition involves bodily contact. Additionally, I am fully aware of my personal medical condition and hereby certify that I am mentally and physically fir to compete at this and any other Great Western Nationals, events or tournaments. I have read and understand and agree to abide by the rules associated with the above listed events and assume any and all associated liability for infringement of such rules. I further agree to indemnify, defend and hold blameless all of the above named parties and persons from any litigation against the same.

ENTER BY DIVISION CODE

DIVISION FEE
1.  $ 
2.  $ 
3.  $ 
4.  $ 
5.  $ 
6.  $ 
7.  $ 
8.  $ 
TEAMS
1. $
ADMISSIONS $
# of T-Shirts Adult M 
Youth S  Adult L  
Youth M  Adult XL 
Youth L   Adult 2X 
Adult S   Adult 3X 
T-Shirt Total $
SUB-TOTAL $
TOTAL $

Applicant's Signature   Date 

Parent's Signature   Date 

Competitor or Parent / Guardian Signature Assuming Responsibility if under 18.