Parent or legal guardian signature is required if participant is under eighteen (18) years of age.

Transcription

1 Individual Waiver Form 2017 U.S. Capital Wushu Championships March 11, 2017 Organized by: Northern Virginia Wushu Academy Form Due by February 10, Or Mail to: NOVA Wushu Academy G Sullyfield Cir. Chantilly, VA LAST NAME: FIRST: MI: STREET: CITY: STATE: ZIP: PHONE (PRIMARY): PHONE (ALTERNATE): DATE OF BIRTH: M / D / Y AGE: SEX (circle one): M F YEARS EXPERIENCE: SCHOOL: PRIMARY INSTRUCTOR: SCHOOL ADDRESS: CITY: STATE: ZIP: PHONE: WAIVER I, the undersigned, knowingly and without duress, do voluntarily submit my entry to the 2016 U.S. Capital Wushu Championships (hereinafter referred to as the Championships ). I hereby assume all risk of physical and mental injuries, disabilities, and losses which may result from or in connection with my participation in the Championships. Hereinafter the Northern Virginia Wushu Academy and NOVA Field House LLC are collectively referred to as the Organizing Committee. Acting for myself, my heirs, personal representatives and assignees, I do hereby release the Organizing Committee, its officers, agents, representatives, servants, employees, volunteers, and all other members from liability due to any injuries incurred and any resulting legal claims, actions, suits or controversies. I also understand that there is risk of injury involved in all the competitive divisions, particularly in fighting events, and I assume full responsibility for all my actions, activities or omissions during and in connection with the Championships. I fully understand that any medical attention or treatment afforded me by the Organizing Committee, its officers, agents, representatives, servants, employees, volunteers, and all other related members will be of the first aid type only, and I hereby release the Organizing Committee, its officers, agents, representatives, servants, employees, volunteers, and all other related members from any liability for such aid. I have read, understand, and agree to abide by the rules of this event, and accept all responsibility and associated liability for infringement of such rules. Additionally, I am fully aware of my personal medical condition and hereby certify that I am mentally and physically fit to compete. I consent to the use of photographs and/or video recordings of my participation in this event for promotional purposes, and hereby waive my rights to any form of compensation or claim. Parent or legal guardian signature is required if participant is under eighteen (18) years of age. Signature of Participant Signature of Legal Guardian Date

2 Registration Form 2017 U.S. Capital Wushu Championships Saturday, March 11, 2017 Important Registration Policies Please read carefully! 1. At the sole discretion of the Organizing Committee, events may be combined or divided at any time prior to competition. 2. All registration forms must be filled out COMPLETELY and ACCURATELY. Both address and phone numbers are REQUIRED. 3. All forms and payment must ARRIVE at NOVA Wushu Academy by mail or hand delivery on or before February 10, NO REFUNDS. Please note that all registration and event fees are non-refundable. If a competitor cannot compete due to a medical reason, a doctor s letter must be provided. Credit will be applied to the following year s competition. / / First Name Last Name Birthday (mm/dd/yyyy) Phone School Please complete the following steps and calculate your fees accordingly. 1 Sex: Male Female 2 Level of Experiences: (Please one No separate experience level) Beginner (0-2 years) Intermediate (No more than 4 years) Advance 3 Age Group: (Please one) Group 1: 6 years old and under, male or female Group 2: 7-9 years old, male or female Group 3: years old, male or female Group 4: years old, male or female Group 5: years old, male or female Group 6: years old, male or female Group 7: years old male or female Group 8: 56 years old & over, male or female 4 Events: (Please write event code in boxes **please see list of events**) 5 All-Around Champion: (Please one) All-Around Champion Group 1: 12 years old and under, male or female All-Around Champion Group 2: years old, male or female All-Around Champion Group 3: years old, male or female All-Around Champion Group 4: years, male or female All-Around Champion Group 5: 56 years old and above, male or female 6 USAWKF National Traditional Team Qualification: (Please one) 2017 USAWKF National Traditional Team Qualifier

3 Early Registration Fees Quick Lookup (Sept. 3 rd, 2016 Nov. 4 th, 2016) Up to 4 Events: $90 5 Events: $110 All-Around: $30 Traditional Team Qualifier: $30 Group Competition: $200 Team Competition: $125 Fees Quick Lookup (Nov. 5 th 2016 Feb. 10 th, 2017) 1-2 Events: $90 3 Events: $110 4 Events: $130 5 Events: $150 All-Around: $30 Traditional Team Qualifier: $30 Group Competition: $400 Team Competition: $250 7 Payment method: (To ensure payment credited correctly, please enclose a copy of the payment receipt if paid by credit card) Pay by Credit Card at Check or Money Order: Please make your check or money order payable to: NOVA Wushu Academy. 8 Mail payment and completed registration, and waiver forms to: NOVA Wushu Academy, G Sullyfield Cir., Chantilly, VA (please reference participant s name on the check)

4 Tournament Events * All standard forms are those established by IWuF. ** Optional forms are individual, self-created forms not established by IWuF. Nandu rules will be applied. *** Optional Long Fist with Music forms are individual, self-created forms not established by IWuF. Nandu rules will be applied. Contempoary Wushu Hand Forms Traditional Long Weapons 1000 Elementary Long Fist (IWuF) * 1061 Traditional Staff 1001 Standard Long Fist (IWuF 1st set)* 1062 Traditional Southern Staff 1002 Standard Long Fist (IWuF 2nd set)* 1063 Other Traditional Staff 1003 Standard Long Fist (IWuF 3rd set)* 1064 Traditional Spear 1004 Other Long Fist 1065 Other Traditional Spear 1005 Optional Long Fist** 1066 Pudao 1006 Optional Long Fist with Music*** 1067 Traditional Kwandao 1007 Standard Southern Fist (IWuF 1st set)* 1068 Other Traditional Long Weapons 1008 Standard Southern Fist (IWuF 3rd set)* 1069 Traditional Soft Weapons 1009 Other Southern Fist 1070 Three-section Staff 1010 Optional Southern Fist ** Section Single Whip Contemporary Wushu Short Weapons 1072 Double Whip or Whip with Sword 1011 Elementary Broad Sword (IWuF) 1073 Other Traditional Soft Weapons 1012 Other Broad Sword Taiji Hand Forms 1013 Standard Broad Sword (IWuF 1st set)* Taiji Quan 1014 Standard Broad Sword (IWuF 2nd set)* Taiji Quan 1015 Standard Broad Sword (IWuF 3rd set)* 1076 Yang Taijiquan 1016 Optional Broad Sword** 1077 Chen Taijiquan 1017 Standard Southern BroadSword (IWuF 1st set)* 1078 Wu Taijiquan 1018 Standard Southern BroadSword (IWuF 3rd set)* 1079 Sun Taijiquan 1019 Other Southern Broad Sword 1080 Wu haotaijiquan 1020 Optional Southern Broad Sword** 1081 Mulanquan 1021 Elementary Straight Sword (IWuF)* 1082 Other Taiji Quan 1022 Other Straight Sword 1083 Optional Taiji Quan ** 1023 Standard Straight Sword (IWuF 1st set)* Taiji Weapons 1024 Standard Straight Sword (IWuF 2nd set)* 1084 Yang Taiji Broad Sword 1025 Standard Straight Sword (IWuF 3rd set)* 1085 Chen Taiji Broad Sword 1026 Optional Straight Sword** 1086 Other Taiji Broad Sword Contemporary Wushu Long Weapons 1087 Yang Taiji Straight Sword 1027 Elementary Staff (IWuF)* 1088 Chen Taiji Straight Sword 1028 Other Staff Taiji Straight Sword 1030 Standard Staff (IWuF 1st set)* 1090 Wudang Taiji Straight Sword 1031 Standard Staff (IWuF 2nd set)* 1091 Other Taiji Short Weapons 1032 Standard Staff (IWuF 3rd set)* 1092 Other Taiji Long Weapons 1033 Optional Staff** 1093 Optional Taiji Sword ** 1034 Elementary Spear (IWuF)* Duilian 1035 Other Spear 1094 Wushu Barehand Duilian 1036 Standard Spear (IWuF 1st set)* 1095 Taiji Barehand Duilian 1037 Standard Spear (IWuF 2nd set)* 1096 Wushu Weapon Duilian 1038 Standard Spear (IWuF 3rd set)* 1097 Taiji Weapon Duilian 1039 Optional Spear** Group 1040 Other Southen Staff 1098 Group Kung Fu 1041 Standard Southen Staff (IWuF 1st set)* 1099 Group Chen Taiji 1042 Standard Southen Staff (IWuF 3rd set)* 1100 Group Yang Taiji 1043 Optional Southern Staff** 1101 Group Taiji Fan Traditional Hand Forms 1102 Group Taiji Sword 1044 Traditional Northern Fist 1103 Group Health Qigong 1045 Traditional Southern Fist 1104 Other 1046 Other Traditional Fist Combined Team Competition (New) 1047 Xingyi, Bagua, Baji, Fanzi 1105 Optional Long Fist**

5 1048 Ditang, Pigua, Tongbei 1106 Optional Southern Fist ** 1049 Chaquan, Huaquan,Paoquan 1107 Optional Broad Sword** 1050 XiangxingQuan (Animal Styles) 1108 Optional Straight Sword** Traditional Short Weapons 1109 Optional Southern Broad Sword** 1051 Traditional Broadsword 1110 Optional Staff** 1052 Traditional Southern Broadsword 1111 Optional Spear** 1053 Other Traditional Broadsword 1112 Optional Southern Staff** 1054 Traditional Twin Broadsword 1113 Optional TaiJi Fist** 1055 Traditional Straight Sword 1114 Optional TaiJi Sword** 1056 Other Traditional Straight Sword 1057 Traditional Twin Straight Sword 1058 Other Traditional Single Short Weapon 1059 Other Traditional Twin Short Weapon 1060 Kung Fu Fan (Single/Twin)