Nickel Belt Budokan Annual Shiai Register Online

$30 DIVISIONS 1 - 3 Family rate: Three or more Judoka competing in these divisions. $60.00
$35 DIVISIONS 4 - 7 Family rate: Three or more Judoka, each competing in one division. $90.00
Extra Division (ONE DIVISION EXTRA ONLY DIVISION $20)

A Separate Form Must be Completed For Extra Division

Payment can be made by Cheque (payable to YMCA Sudbury), Visa, Mastercard, or American Express.
Mail: 140 Durham Street
or Fax: (705) 675-8777
Sudbury, ON P3E 3M7

You may have up to two entries per person. If this is your second entry, please check here:

First Name:
Last Name:

Email Address:

Phone Number:

Daytime Contact Phone Number:
The YMCA will contact you for billing information. Phone Number:

Number of Tournament Shirts ($25 each):
XXL, XL, M, S
If you are ordering more than one, list them with size and quantities

Division:
JUNIOR 1 2 3
JUVENILE 4
I.J.F. JUNIOR 5
SENIOR 6
MASTER 7
GRAPPLING CHALLENGE 8

Weight Division:

Age:

Date of Birth:

Rank:

Gender:

Judo Club:

Canadian Membership:
Judo Ontario Membership Number or YMCA Membership Number

Judo Canada Passport Number:

Other Provincial Association Number: (Description and number)

USA Membership:
USJI , USJF, USJA, Registrant Number

Sensei Name:

PROVINCIAL / STATE HEALTH CARD # (OPTIONAL):

Address:

City:

Province/State:

Postal Code/Zip Code:

Country:

TOURNAMENT LIABILITY WAIVER

This waiver must be completed when registering. If the registrant is under 18 years of age, the waiver must be signed by the registrant’s parent(s) or guardian(s).

In consideration of my registration as a participant in the tournament to which this registration form applies, I do hereby remise, release and forever discharge Nickel Belt Budokan Judo Club, YMCA Sudbury and Judo Ontario (also known as the Ontario Judo Black Belt Association), City of Sudbury and any other clubs, persons, firms, associations, or corporate bodies participating in or connected with any practice session, exhibitions, games, contests, tournament matches, or any other event or exercise connected with this tournament, for any loss, damage, or injury sustained, or in respect of the loss of any equipment used during the course of this tournament.

I hereby verify that all the signatures and information contained in this form are correct, and that this form bears the signature of the registrant’s parent or legal guardian, where the registrant is under 18 years of age.

Dated at:

Registrants Name:

Registrants Signature if over 18 (Type Name in Box):

Registrants Guardian Signature if under 18 (Type Name in Box):

Registrants Guardian Name: