14th GOLDEN STATE OPEN TAEKWONDO CHAMPIONSHIP OFFICIAL MASTERS AND VIP APPLICATION Saturday, March 27, 2010 Kellogg Gym @ Cal Poly Pomona 3801 W. Temple Ave, Pomona, CA 91768 SATURDAY        7:00 - 8:00 AM                                     Competitior Card Pickup                          8:30 AM                             Poomse Competition Begins                          10:00 - 10:30 AM     14-32 Black Belt Weigh In * (Holding Area) I AM SIGNING UP FOR: (Please Choose) Master VIP First Name:      Middle:      Last Name: Home Street Address:      Apt#: City, State, Zip:      Email: Daytime Phone:      Ext:      Age:      Birthdate (mm/dd/yyyy): TKD School Name:      Masters Name: TKD School Street Address:      TKD City, State, Zip: TKD Phone:     RANK / DAN:      KUKKIWON CERTIFICATE #:       Liability Waiver and Consent to Medical Treatment I hereby submit this registration and liability waiver form to participate in the Golden State Open Taekwondo Championship. I certify that above information is true and correct and hereby release, discharge, and waive any and all responsibility of the Kellogg Gym, Calif. State Polytechnical University, Pomona, S.K. Taekwodo Center, California Taekwondo, Tournament Organizing Committee, referees, instructors, agents, and other competitors from liability for any injury, including death, and for damage to or loss of property which may be suffered by myself arising out of, or in any way resulting from or attributable in whole or in part to my traveling to, training to, being coached in, using any sports equipment in, or participating in the Golden State Open Taekwondo Championship. As a competitor or parent/legal guardian of the competitor, I give consent to any x-ray exam, medical, chiropractic, dental or other treatment(s) deemed necessary for the safety and welfare of the contestant. I understand that this authorization is given prior to any diagnosis, treatments or hospital care being required, but is given to provide the medical / chiropractic / dental staff authority to render care as deemed advisable. In the case of minors, it is understood that efforts shall be made to contact the undersigned prior to rendering treatment, but treatment will not be withheld if the undersigned cannot be reached. I understand that in case of injury, only basic first aid will be made available on site, and that I am fully responsible for any and all resulting medical or other expenses. If you are over 18 years of age, please answer: (MUST CHOOSE) I AGREE I DO NOT AGREE                                                             Please make sure all information have been completed before submitting application.