14th GOLDEN STATE OPEN TAEKWONDO CHAMPIONSHIP OFFICIAL REFEREE'S 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) First Name:      Middle:      Last Name: Home Street Address:      Apt#: City, State, Zip:      Email: Daytime Phone:      Ext:      Age:      Birthdate (mm/dd/yyyy): TKD School Name:      Address:       TKD City, State, Zip:      TKD Phone:      REFEREE SEMINAR Saturday, March 13, 2010 (2-5PM) @S.K. TAE KWON DO CENTER 9569 Las Tunas Drive Temple City, CA 91780 Phone: 626-286-6500 / Fax: 626-286-7300 GOLDEN STATE OPEN TKD COMPETITION Saturday, March 27. 2010 Kellogg Gym@ CAL POLY POMONA 3801 West Temple Ave Pomona, CA 91768 Taekwondo Rank   (Please Select) Color Belt Black Belt  Dan          Referee Rank (if applicable): I WILL ATTEND (check all that apply): Referee Seminar     Dinner After Seminar     The GSOTKDC     Dinner After GSOTKDC I AM ABLE TO PARTICIPATE AS (check all that apply): Center Referee     Corner Judge     Technical Assistant     Ringmaster Operator       Referee Incentives (For referees who attend the seminar and serve at the GSOTKDC) * FREE REFEREE SEMINAR * FREE DINNER AFTER SEMINAR * FREE REFEREE POLO SHIRT * OFFICIATING CERTIFICATE * COMPLIMENTARY LUNCH & BEVERAGES * FREE DINNER AFTER GSOTKD TOURNAMENT * $50 REWARD FOR ALL CERTIFIED REFEREES * $100 REWARD FOR ALL INT'L REFEREES POLO SHIRT SIZE: (Please Choose) Adult Small Adult Medium Adult Large Adult X-Large Adult XX-Large            ALL REFEREES MUST WEAR BLACK PANTS AND TKD SHOES. SHIRTS WILL BE PROVIDED       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.