West Mesa High School

Saturday, April 9, 2011

Forms - Point Sparring - Olympic Sparring – Creative Forms –Team Forms- Breaking- Matted rings & Electronic Scoring

West Mesa High School

6701 Fortuna Rd. NW

Albuquerque NM 87121

Registration 8 a.m.

Tournament Begins 9 a.m.

Send Applications and Cashiers check or Money Order by April 1, 2011 to

Takai Mine Karate/TKD, 1027 Juan Tabo NE, Albuquerque, NM 87111

SANCTIONED BY THE

NEW MEXICO AMATEUR ATHLETIC UNION

Qualifier for Nationals in Austin, Texas

June 27-July 2, 2011

For more information contact

Master Antionette Chavez

1027 Juan Tabo NE, Albuquerque, NM 87112

505-294-6302

takaiminekarate.com

2011 New Mexico AAU Tae Kwon Do Championship

April 9, 2011

West Mesa High School

6701 Fortuna Rd., Albuquerque, NM 87121

Individual Competitor’s Registration Form

Last Name ______First Name ______MI ______

Street Address ______

City ______State ______Zip Code ______

Phone ______Email ______Age ______DOB ______

Weight ______Height ______Male ___ Female ___ AAU Number ______

Price: $50.00 for 1 event, each additional event $10 per event

Money order or cashier’s checks only. Mail to Takai Mine Karate/Tae Kwon Do, 1027 Juan Tabo NE, Albuquerque, NM. 87112, by April 1, 2011 without penalty. $15.00 late registration fee if received after April 1, 2011.

Novice:White ____Yellow _____Orange ______

Intermediate:Green ____Blue ______Purple ______

AdvancedRed ______Brown _____1st, 2nd Gups ____

Black Belt:1st ___ 2nd ___ 3rd ___ 4th ___ 5th ___ 6th ___

Event(s): Please place a check mark in the appropriate event (s) you are competing in.

Forms ______Point Sparring _____Olympic Style Sparring _____

Breaking _____Weapons/Creative Forms _____

3 person Team Forms_____ (Black Belts Only)

*Each Team Form Member must fill out an individual application

(If you are interested in representing New Mexico in Austin, Texas, please check here: _____)

Martial Arts School ______Phone ______

Instructor ______Email :______

School Address ______

Liability Waiver

I, the undersigned, for myself, my heirs, administrators and assigns, do hereby covenant and agree as follows. I hereby assume all risk of any personal injury which may result from activities in which I engage at the 2011 New Mexico AAU Championship including supervised and unsupervised activities; that I for myself, my heirs, administrators and assigns, do hereby release Master Antionette Chavez, Takai Mine Karate, West Mesa High School, all coaches, officials, individually or collectively, from all liability, including claims at law or in equity for any injury, fatal or otherwise, mental or emotional damages, which may result directly or indirectly from my traveling to, participating, or returning from set tournament or related functions. I understand that Tae Kwon Do/Martial Arts is a contact sport with a risk of serious injury, possibly death, to me, or my children who may enter said tournament. I also assume all risk of my personal property at the tournament premises if lost or stolen. I also understand that there are no refunds.

I have read and fully understand the above waiver and agree with its terms.

______

Signature of competitor if 18 or olderDate

______

Signature of Parent or Legal Guardian if under 18 Years of AgeDate