REFEREE  APPLICATION
23rd GOLDEN STATE OPEN TAEKWONDO CHAMPIONSHIP
OFFICIAL REFEREE'S APPLICATION
Saturday, March 30, 2019
Kellogg Gym @ Cal Poly Pomona
3801 W. Temple Ave, Pomona, CA 91768
SATURDAY           7:00 - 8:30AM   COMPETITOR CARD PICKUP (Front of Gym)
                               9:00 AM             ALL BELTS 7 & Under Form & Sparring
                             1:30 PM             ALL BELTS 8 & Above Form & Sparring
First Name:      Middle:      Last Name:
Home Street Address:      Apt#:
City, State, Zip:      Email:
Contact #:           Age:      Birthdate (mm/dd/yyyy):
TKD School Name:      Address:      
TKD City, State, Zip:      TKD Phone:     

REFEREE SEMINAR
Saturday, March 16, 2019
(3:30-6:30PM)

@ SK TAEKWONDO CENTER
9569 Las Tunas Drive
Temple City, CA 91780

Phone: 626-286-6500
E-Mail: GSOTKD@Hotmail.com



GOLDEN STATE OPEN
TAEKWONDO CHAMPIONSHIP

Saturday, March 30, 2019
Kellogg Gym@ CAL POLY POMONA
3801 West Temple Ave
Pomona, CA 91768



Taekwondo Rank    Dan          Referee Rank (if applicable):
I WILL ATTEND (check all that apply):
Referee 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 REFEREE POLO SHIRT
* OFFICIATING CERTIFICATE
* COMPLIMENTARY LUNCH & BEVERAGES
* FREE DINNER AFTER GSOTKD TOURNAMENT
* MONETARY REWARD FOR REFEREES!
        **REGIONAL REFEREES = $75 AWARD
        **USAT-CERTIFIED REFEREES = $100 AWARD
        **INTERNATIONAL REFEREES = $150 AWARD
POLO SHIRT SIZE:           
ALL REFEREES MUST WEAR BLACK PANTS AND WHITE 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 United, Tournament Organizing Committee, referees, instructors, agents, volunteers 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:


                                                           
Please make sure all information have been completed before submitting application.