UAA Judo and Jiu Jitsu Presents Judo and Jiu Jitsu Black Belt 2x Olympian 2x PanAm Games Champion 2x Copa Podio Finalist Over 30 International Medals Top 5 World Ranking Athlete Greatland Martial Arts - Anchorage 520 W. 58th Ave. Anchorage, AK Saturday, February 18, 2017 Judo Sunday, February 19, 2017 - Jiu Jitsu - Jiu Jitsu Children's Judo 10:00 AM Noon Children's Jiu Jitsu 10:00 AM Noon Intermediate Judo 2:00 PM 4:00 PM Intermediate Jiu Jitsu 2:00 PM 4:00 PM Advanced Judo 6:00 PM 9:00 PM Advanced Jiu Jitsu 6:00 PM 9:00 PM *Judo Sessions require Judo member ship with *Jiu Jitsu Sessions require USA Judo Jujitsu membership USA Judo, USJA, or USJF USA Judo on-line membership registration: https://webpoint.usjudo.org/wp/memberships/join.wp Clinic Rates 1 Session 2 Sessions 3 Sessions 4 Sessions First Family Member $30 $45 $55 $60 Second Family Member $25 $35 $45 $50 Third Family Member $15 $25 $35 $40 Fourth Family Member Free $10 $20 $30 Additional Family Members Free e.g. A family of four with 1 member attending 4 sessions ($60), 1 member attending 3 session ($45), 1 member attending 2 sessions ($25), and the last member attending 1 session (free) would be $130 for the family. Call (907)529-5078 for more information
Train with a Champion Clinic Registration February 18 & 19, 2017 Sanction # 12448 Name # Sessions Reg. # Exp. Date Club: Total Fee: Address: Phone: Email Address: mailing lists: Judoka Referee Club List If you want your email address added to a list, you must check its check box. Home Phone: Emergency Phone: If assistance/accommodation is needed (check off appropriate box): Vision Loss/Blindness Hearing Loss/Deafness Type of assistance/accommodation requested or name of person assisting: Location: Greatland Martial Arts Anchorage (520 W. 58 th Ave. Anchorage, AK) Dates/Times: Saturday, February 18, 2017 Judo Sunday, February 19, 2017 - Jiu Jitsu - Jiu Jitsu Children's Judo 10:00 AM Noon Children's Jiu Jitsu 10:00 AM Noon Intermediate Judo 2:00 PM 4:00 PM Intermediate Jiu Jitsu 2:00 PM 4:00 PM Advanced Judo 6:00 PM 9:00 PM Advanced Jiu Jitsu 6:00 PM 9:00 PM *Judo Sessions require Judo member ship with USA *Jiu Jitsu Sessions require USA Judo Jujitsu membership Judo, USJA, or USJF Families, for this event, USA Judo is allowing families to register for both memberships at the family Judo rate! You must use the attached family membership form. Clinic Rates 1 Session 2 Sessions 3 Sessions 4 Sessions First Family Member $30 $45 $55 $60 Second Family Member $25 $35 $45 $50 Third Family Member $15 $25 $35 $40 Fourth Family Member Free $10 $20 $30 Additional Family Members Free e.g. A family of four with 1 member attending 4 sessions ($60), 1 member attending 3 session ($45), 1 member attending 2 sessions ($25), and the last member attending 1 session (free) would be $130 for the family. Family members are order by the number of sessions they are participating in. THE RELEASE AND WAIVER FOLLOWING THIS FORM MUST BE CAREFULLY REVIEWED AND SIGNED BY THE PARTICIPANT(S) AND THEIR PARENT(S) OR GUARDIAN(S), IF THE PARTICIPANT IS A MINOR. FAILURE TO SIGN THE WAIVER WILL RESULT PROHBIT THE PARTICIPANT FROM PARTICIPATING IN THE CLINICS. THE USA JUDO MEMBERSHIP APLICATION ONLY NEEDS TO BE FILLED OUT IF YOU ARE USING IT TO APPLY FOR MEMBERSHIP.
WARNING! WAIVER AND RELEASE OF LIABILITY AND AGREEMENT TO PARTICIPATE In consideration of being permitted to participate in any way, including travel to and from, in any Judo tournament, practice, clinic, and related events and activities ( Activity ) of the USA Judo/United States Judo, Inc., United States Judo Federation, Inc., United States Judo Association, Inc., Alaska Judo, Inc., UAA Judo and Jiu Jitsu Club, Greatland Martial Arts, and the University of Alaska Anchorage, I agree: 1. I understand the nature of Judo and Jiu Jitsu activities and believe I am qualified to participate in such Activity. I also understand the rules governing the sports of Judo and Jiu Jitsu. 2. I further acknowledge that prior to participating, I will inspect the mats, equipment, facilities, and if I believe anything is unsafe or beyond my capability, I will immediately advise my coach, supervisor, and/or a clinic official of such conditions and refuse to participate. 3. I acknowledge and fully understand that I will be engaging in a contact sport that might result in serious injury, illness or disease, including permanent disability or death, and severe social and economic losses due not only to my own actions, inactions or negligence, but also to the actions, inactions, or negligence of others, the rules of the sports of Judo or Jiu Jitsu, or conditions of the premises or of any equipment used. Further, I acknowledge that there may be other risks not known to me or not reasonably foreseeable at this time. 4. Knowing the risks involved in the sports of Judo and Jiu Jitsu, I assume all such risks and accept personal responsibility for the damages following such injury, illness, disease, permanent disability, or death. 5. I hereby release, waive, discharge and covenant not to sue the USA Judo/United States Judo, Inc., United States Judo Federation, Inc., United States Judo Association, Inc., Alaska Judo, Inc., UAA Judo and Jiu Jitsu Club, Greatland Martial Arts, and the University of Alaska Anchorage, together with their affiliated clubs, their respective administrators, directors, officers, agents, coaches, and other employees or volunteers of the organization, event officials, medical personnel, other participants, their parents, legal guardians, supervisors and coaches, sponsoring agencies, sponsors, advertisers, and if applicable, owners, lessors, and lessees of premises used in conducting the event, all of whom are hereinafter referred to as "Releasees", from any and all litigation expenses, attorney fees, loss, liability, damage or costs on account of injury, illness, disease, including permanent disability and death or damage to property, caused or alleged to be caused in whole or in part by the negligent acts or omissions of the Releasees or otherwise to the fullest extent permitted by law. I HAVE READ THE ABOVE WARNING, WAIVER, AND RELEASE, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND KNOWING THIS, SIGN IT VOLUNTARILY AND WITHOUT ANY INDUCEMENT OR ASSURANCE OF ANY NATURE. CONSISTENT WITH THE BY-LAWS OF USJF, THIS TOURNAMENT MAY INCLUDE CO-ED COMPETITION FOR AGES 10 AND UNDER IN COMPARABLE AGE/WEIGHT DIVISIONS WHERE THERE IS AN INSUFFICIENT NUMBER OF GIRLS FOR NON-CO-ED AGE/WEIGHT DIVISIONS. I HAVE READ AND UNDERSTAND THE TOURNAMENT ANNOUNCEMENT CONCERNING THESE SPECIAL DIVISIONS. I AGREE TO PARTICIPATE KNOWING THE RISKS AND CONDITIONS INVOLVED AND DO SO ENTIRELY OF MY OWN FREE WILL. I AFFIRM THAT I AM AT LEAST 18 YEARS OF AGE, OR, IF I AM UNDER 18 YEARS OF AGE, I HAVE OBTAINED THE REQUIRED CONSENT OF MY PARENT/LEGAL GUARDIAN AS EVIDENCED BY THEIR SIGNATURE BELOW. I INTEND THIS TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST EXTENT ALLOWED BY LAW AND AGREE THAT IF ANY PORTION OF THIS AGREEMENT IS HELD TO BE INVALID THAT THE BALANCE, NOTWITHSTANDING SHALL CONTINUE IN FULL FORCE AND EFFECT. Participant Participant s Signature Date FOR PARENTS/LEGAL GUARDIANS OF PARTICIPANTS OF MINORITY AGE (UNDER AGE 18 AT TIME OF REGISTRATION) This is to certify that I, as parent/legal guardian with legal responsibility for this participant, do consent and agree to his/her release, as provided above, of all the Releasees, and, for myself, my heirs, assigns, and next of kin, I release and agree to indemnify and hold harmless the Releasees from any and all liabilities incident to my minor child s involvement or participation including litigation expenses, attorney fees, loss, liability, damage or costs which may incur as the result of the minor child s participation in these programs as provided above, even if arising from their negligence, to the fullest extent permitted by law. I have instructed the minor participant as to the above warnings and conditions and their ramifications. Parent/Legal Guardian Parent/Legal Guardian s Signature Date
USA JUDO MEMBERSHIP APPLICATION 1 Olympic Plaza Colorado Springs, CO 80909 Tel (Ntl.Office): 719-866-4730 Fax: 719-866-4733 Save Time and Money, Register on Line www.usjudo.org *Name: *Address: First Mi Last *City: *State: *Zip: * Phone: Mobile: *Email: *Date of Birth: Age: *Sex: *Citizenship: Club/Dojo: Judo Rank: Optional: Include a copy of your passport or birth certificate and rank for verification on your membership card. *REQUIRED INFORMATION JUDO JUDO AND JUJITSU New Member-16 and under $40.00 Family Membership 3-4 members $125.00 New Member-17 and over $70.00 Family Membership 5 members $155.00 Renewing Member-All ages $70.00 Family Membership 6 members $185.00 Existing Life Member $35.00 JUDO AND JUJITSU Jujitsu $70.00 Dual membership $100.00 30 Day Trial Membership* $20.00 Plastic Membership Card Will Be an Additional $5.00 Charge Memberships are Non-Transferable/Non-Refundable *Trial Memberships are good for 30 days from date of application. Trial membership fee will be applied to full membership if applicant elects to join USA Judo as a full member at full membership fee. All other memberships are valid for one (1) year from date of application. Visa Name on Card: MasterCard Discover Account #: Exp. V Code: CC Amount: Amer Express Billing Address: Check #: ($25.00 return check fee) Cardholder DONATION: $ TOTAL AMOUNT SUBMITTED: Prices Effective 4/12/15 Page 1 of 2
permitted by law, USA Judo, USJA and/or USJF from or for all claims demands and causes of actions or any other liabilities which may arise by thereof of USA Judo, USJA and/or USJF and agree that I know and understand the risks involved in the sport of Judo/Jujitsu and do hereby assume I agree to be filmed and photographed under conditions approved and authorized by USA Judo, to include the use of my name, biographical information, public appearances, interviews, photographs, portrait and motion pictures and television recordings of my judo performance/participation and grant to USA Judo and Organizers the right to record and make use of the same, and to authorize others to do so in promoting the competition and the success of the judo team on which I compete, to promote the image of USA Judo, its sponsors and advertisers, and the sport of amateur judo, and to fund the activities of the USA Judo. I state that I am the parent(s) or legal guardian of the applicant, a minor. I state that I have read and substantial rights by signing and submitting the application and instructing her/him of the ramifications and that I/we consent to the applicant(s) becoming a member of USA Judo and participating in Judo/Jujitsu practices, clinics and events sanctioned or sponsored by USA Judo, USJA and/or USJF. The above releases must be signed for this application to be valid. 2. Name: Mobile: Judo Rank: 3. Name: Mobile: Judo Rank: 4. Name: Mobile: Judo Rank: 5. Name: Mobile: Judo Rank: 6. Name: Mobile: Judo Rank: The Family Membership Releases/Waivers must be signed and attached for this application to be valid PAGE 2 OF 2
USA JUDO and JUJITSU FAMILY MEMBERSHIP WAIVERS FAMILY MEMBER #2 NAME: FAMILY MEMBER #3 NAME: The above releases must be signed for the membership application to be valid.
FAMILY MEMBER #4 NAME : FAMILY MEMBER #5 NAME : The above releases must be signed for the membership application to be valid.