The 26th Annual Kick Cancer Out of The World

Taekwondo Championship Official Entry Form

There will be no on-site registration for the championship this year. Only spectator fees will be collected.
Date: Saturday, October 13, 2018
Place: Douglass Community Center 407 E. Market Street Leesburg, VA 20176

Fees: Registration by mail postmarked no later than October 08, 2018. No personal checks. Cash, Cashier’s checks or Money orders ONLY!
Make payable to USTMA. NON-REFUNDABLE. Send to 9 Cardinal Park Dr. Leesburg, VA 20175
One Event: $80.00 | Each Additional: $20.00 | Family Poomsae: $20.00 per competitor | Tag Team Sparring $100.00 per
group
General Admission: $10.00 (under age of 5 and senior citizens are Free) All proceeds benefit Blue Ridge Hospice
Name: Address:
City: State: Zip: Phone (C): Phone (W):
Age: Sex: Weight: Height:
Belt: Dan: TKD Academy Name:
City: State: Zip: Master/Instructor’s Name:
Please check all events you are entering below:
__ Sparring D1 (head contact) __ Sparring D2 (no head contact) __ Team Sparring __ Poomsae __Gyukpa (Board Breaking) __ Family Poomsae
See reverse side for rules/pricing details
All competitors in the championship must have:
1. Their own WTF approved sparring gear consisting of: Traditional V-Neck uniforms, shin and instep protectors, forearm guards, a chest protector, headgear,
mouth piece, and protective cup (for male competitors). All protective equipment listed above is required. Competitors will not be allowed to compete
without proper gear.
2. Boards for Breaking. For fairness of judging, boards must be purchased at the competition.
Liability Waiver: I hereby submit my application to the 2018 Cancer Benefit Championship. I hereby agree to waive claims against any person, school (academy),
or association connected with Grand Master Choi for any injuries I may sustain, and likewise will assume full responsibility for all my actions in connection
with the championship. I further agree that any video tape or still pictures taken of me in connection with the championship can be used by the tournament director
for publicity or promotion without compensation at this time or any other time in the future.

Signature: Master/Instructor’s Signature:

I verify that the applicant is a student at my school and that the above information is correct.

Sparring D1 (Light Head) Tag Team Sparring Forms (Poomsae)

D2 (No Head) $100 per group
Name
Name Name /Rank of each team member: TKD School
TKD School

Sex Wt
Sex Wt TKD School Age Age Division
Age Division 1 or 2: *Teams must be 3 members of same gender Belt Dan
14-17 year old Black Belts ONLY
Belt Dan

Breaking (Gyuckpa) Family Poomsae

$20 per competitor
Name

TKD School Names

Sex Wt
TKD School
Age Age Division
Total # of Members: ______
Belt Dan
Must have 1 parent participant