Name: Age: Rank:
Address: City: State: ZIP:
Phone: School: Instructor:
E-mail address: Division:
Check all that apply........................... Self-Defense: Breaking: Weapons: Kata: Kumite: Grappling-Gi: Grappling-No-Gi:
To register, print this form and send via US Mail with the appropriate payment to:
Master Curtis Smith Universal Professional Training P.O. Box 7590 Oakland Station Pittsburgh, PA 15213
Pre-Registration Cost - $40 1 event, $45 2 events, $50 up to 5 events if received before 11/30/09 Cost after 11/30/09 is $45 1 event, $50 2 events, $55 up to 5 events
$5 discount for PKC members
Non-competitors will not be allowed onto the competition floor during the tournament. Coaching will not be permitted at ringside or from the stands. Video Pass Received by 11/30/09........................$10 After 11/30/09........................$15 I hereby waive any and all rights or claims I may have against Master Curtis Smith, Universal Professional Training, East/West Martial Arts Club, The Professional Karate Commission, The University of Pittsburgh, servants and employees, and all others affiliated with the Ultimate Force tournament. I release and discharge them from any and all claims resulting from injuries, including death, damages, or loss which may accrue to myself or my heirs arising out of or in any way connected with my attendance to and participation with this and any Ultimate Force events. I represent and warrant that I am physically and mentally fit, able to participate, and do hereby assume responsibility for my own well-being, understanding that participation may involve bodily contact. I consent to allow any reproductions of myself or likeness created in any manner, photographed or filmed, in connection with Universal Professional Training and Professional Karate Commission events to be used for instruction, publicity, promotion, or television broadcast and I waive any and all compensation in regards thereto. Non-competitors will not be allowed onto the competition floor during the tournament. Coaching will not be permitted at ringside or from the stands.
Self-defense, breaking, weapons, and forms are all medal events. In all divisions, 4th-6th places are medal positions
