2012 Windy City 20th

WCT 20th Traditional Japanese Shotokan & Okinawan Annual National Invitational Karate Tournament Friday & Saturday, March 2 & 3, 2012 Phone 847-797-1989
Athlete Number:_____________ Circle Gender Age M D Year

Crowne Plaza Hotel, 5440 North River Road, Rosemont, Illinois 60018 (call for reservations 888-233-9527).
Print Your Name or Type in the Boxes below

First Name

Last Name

Athlete Phone No: __________________________________E-mail:__________________________________________________ Circle Rank: 10kyu 9kyu 8kyu 7kyu 6kyu 5kyu 4kyu 3kyu 2kyu 1kyu Sho-Dan Ni-Dan San-Dan Above

Club Name:____________________________________ Instructor Name:______________________________________________ Club Phone No:(______)_________________________ Club E-mail:__________________________________________________

Friday Seminar Fee: Please mark with an X on how many seminars you will be attending.

1 Event: $40 2 Events: $75 (A) Tai-chi Noon Sensei Frank Gaviola (D)
Shifting & Sweeps 3:00 p.m. Sensei Vern Vadin

3 Events: $90 4 Events: $100 5 Events $120 6 Events $140 (B) Kumite Go-No-Sen
1:00 p.m. Sensei James Yabe at

Please mark with a X the seminar(s) you will be participating in:

(C) Nunchaku
2:00 p.m. Sensei Brian Ricci

(E) Sai
4:00 p.m. Sensei Devorah Dometrich

(D) Kata Goju-shi-ho-Sho

5:15 p.m. Sensei Joe Gonzalez Judges Clinic: all Club Directors & Black Belt adult students, please mark with an X if you are attending: Yes NO

Competition Fee: Please mark with an X how many events you will be participating in:

1 Event: $40 2 Events: $75

Age

3 Events: $90 4 Events: $100 5 Events $120 6 Events $140

Team Kata Ippon Kumite Kumite Team Kumite Weapon (Kobudo)

Place an X in the row that corresponds with your age and the event(s) you will be competing in:
Kihon Kata

5-6 7-8 9-12 13-17 18-56 57-65

No Event No Event No Event

No Event

No Event

No Event No Event No Event No Event

No Event No Event

No Event

No Event

Teams please enter the names of your team mates:

Kata Team Mates: 2._______________________________ 3.___________________________________________ Kumite Team Mates: 2._____________________________ 3.__________________________________________ Kumite Team Alternate:____________________________ __. Banquet on Saturday, March 3rd at 7:30 p.m. Attending # _____ x $50 = $ ______ Total: $________ Grand Total $________
Waiver: NO refunds once registered (All Athletes are responsible for their own insurance coverage)
Please print your name: I ___________________________________ with this submit my application for participation in Friday, Saturday, March 2 & 3, 2012, in the Windy City 20th 2012 Traditional Japanese Shotokan & Okinawan Karate Tournament. I understand that there are risks of injury including death involved in participating in the tournament. I claim full responsibility for myself in this event. I hereby waive and release any and all claims, cause of action, losses, damages, cost, expenses, either known, now existing or arising in the future, that I may have of whatever kind or nature against any tournament organizer or director, Crowne Plaza Hotel R Resorts, Rosemont, Illinois or anyone involved in any way with the tournament. Also I agree that the tournament organizer for publicity or promotion can use any photos taken of me during the tournament without compensation to me.

Signature (Parent or Guardian if under 18 years old)

Date

Mail Form(s) with Check or Money Order Payable to W.C.T. 20 th, P.O. Box 1231, Arlington Heights, Illinois 60006 Registration Deadline Postmarked on or before February 10. NO late registration accepted.