Rank
Nov
Inter
Adv
BB
Name
M
Age
F
mm/dd/yy
DOB
Address
Zip
City
State
Instructor's Name
Dojo/Dojang Name
City
Zip
State
Address
Dojo/Dojang Phone
E-Mail Address
Home Phone
Pre-registration fee before March 7, 2012: $45 + $15 (for each additional division)
Registration after March 7, 2012: $50 + 20 (for each additional division)
Spectators Admission: $10
Coach's Pass: $15 Video Camera Pass: $10
Combo pass: 1 Spectator Admission and 1 Coach's pass only $20
Please call 803-286-5155 to register by credit card (service charge $3)
Please put Division
Code(s) in the Proper
Category(s) Below
(use
commas if more than one
division code in category)
# OF DIVISIONS
SPECTATOR
COACH'S PASS
COMBO PASS
VIDEO CAMERA PASS
# of Divisions
0
$ 0.00
$ 45 + (
=
=
=
=
=
-
SELF-DEFENSE
BREAKING
KATA
MUSICAL
WEAPONS
FIGHTING
X $ 15
X $ 10
X $ 15
X $ 20
X $ 10
0
$ 0.00
0
$0.00
0
$0.00
0
$0.00
$ 5.00
Dojo Organization ID #
Total Amount Due
Send Check or Money Order payable to: UKS, 112 E. Gay Street, Lancaster, SC 29720
The person signed below releases Universal Karate Studios and the City of Lancaster it agents or
authorized guest from all injuries or losses that may occr as a result of being present at this event
Signature________________________________________ Date ______________________
Parents or Guardians must sign if under 18 years of age
UNIVERSAL MARTIAL ARTS CHAMPIONSHIP 2012
PRE-REGISTRATION FORM
(MUST BE RECEIVED BY MARCH 7TH, 2012)