Second_Page_Entry

Please Print OFFICIAL ENTRY FORM Please Print

« FILL OUT DIVISIONS & AGE «

Fees
One Event Before March 20: .............	$40.00 ________	« Weapon ____________________
Each Additional Event: .....................	$10.00 ________	« Form _____________________
One Event After March 20: ................	$45.00 ________	« Sparring _____________________
Each Additional Event: .....................	$15.00 ________	« Self-Defense _________________
Spectator		« Breaking ____________________
Adults: .........................................	$10.00 ________	« Musical ____________________
Children 5-17: ...............................	$ 5.00 ________
TOTAL ENCLOSED è	________

Note: Failure to give truthful complete information may result in disqualification. Proof of Age may be required.

See Division Page to find your division. Enter the complete division names below, including your age, belt color and sex::

Competitors Name __________________________________ Rank ___________ Age ____ Sex ____ Weight _____

Mailing Address _________________________________________ Apt# ______ Phone: ______________________

City __________________________________________State _______ Zip Code ___________________________

Instructor ____________________________________________ Dojo __________________

RELEASE FORM

The undersigned does hereby for himself, herself, his or her heirs, executors, administrators, successors and assigns release and forever discharge the promoter and the organizers of the Montez Dennis 2004 East Coast Martial Arts Challenge held on April 3, 2004 at Bethel High School, Hampton, VA and their servants and agents and all those in any way connected with the running and management of same from any and all actions, caused of actions, claims, and demands for upon or by reason of any damage, loss or injury to person and property and death which heretofore has been undersigned participating in the said tournament. I also hereby agree that any photographs or films of myself, taken at the events may be used by the tournament directors for publication, broadcasting or any other promotional purpose.

E Send entry fees to E. Montez Dennis, 7 Langille Ct., Hampton, VA 23663; before March 20, 2004.

E Postal or money orders or certified checks payable to E. Montez Dennis. (NO BUSINESS OR PERSONAL CHECKS)

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Signature

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Parent/Guardian (Parent/Guardian must sign if under 18 yrs. old)

E Mail all pre-registration forms to E. Montez Dennis, 7 Langille Ct., Hampton, VA 23663; before March 20, 2004. Money orders only please, NO BUSINESS OR PERSONAL CHECKS ACCEPTED. Failure to give truthful information may result in disqualification. Proof of age may be required.