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ONLINE REGISTRATION

USA Taekwondo Referee Certification Seminar

Date: March 7, 2010
Location: Yushen Lai's Taekwondo Academy
111 E. Carson St. #11
Carson, CA 90745
  1. Referee must be age 16 and older, USA Taekwondo athlete and/or referee member, provide proof of 1st degree black belt certification or higher, and pay seminar fee in order to be eligible to receive Referee Certification.
  2. Seminar Fee is $60.
  3. Please bring your dobok, TKD Shoes, note book and pen.
  4. Bring a copy of your Kukkiwon certificate (if applicable)
Applicant Information

First Name: Middle I: Last Name:
Address:
City, State/Zip:
Phone: area code ()   number
E-mail:
Enter "M" for Male or "F" for Female:
Date of Birth (dd/mm/yy):   Age:
U.S. Citizen   U.S. Resident   Other
Black Belt Rank:
Black Belt Number:
Referee Rank:
USAT Membership Number:


LIABILITY WAIVER AND CONSENT TO MEDICAL TREATMENT
I hereby submit this registration and liability waiver form to participate in the USA Taekwondo Referee Certification Seminar. I certify that the above information is true and correct and hereby release, discharge and waive any and all responsibility of the USAT, California Unified Taekwondo Association, Tom Vo Taekwondo Academy, Instructors, and other participants 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 for, being coached in, using any sports equipment in, or participating in the said event. As a participant or parent/legal guardian of the participant, I give consent to any x-ray exam, medical, chiropractic, dental or other treatment(s) deemed necessary for the safety and welfare of the participants. 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.
The Liability Waiver and Consent to Medical Treatment is required for all applicants.
E-signature (initials) of Participant or Parent/Legal Guardian is required:
Legal Parent/Guardian name:
By entering three letters or initials as your E-signature you accept the conditions above.


STEP TWO - Click for PayPal Payment Options





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