East Coast Championships Judo Tournament

Entry Form for Masters and Novice MastersStandard RegistrationPostmarked by May 28thUS FUNDS ONLYFee is Per Entry, Per DivisionNo Exceptions1st Division 502nd Division 30Late Registration Receivedbetween June 2nd and June 6th1st Division 702nd Division 40Note: The Special Family Plan – 1st Division for 2nd & 3rd child is 40.00, 4th child free - is only available forStandard Registration and must be postmarked by May 28, 2014. All applications must be received by June 6th.No walk-up registrations will be allowed.Make all checks payable (US Funds Only) to “Kokushikai Inc” and mail to:Celita Schutz ECC24-28 Fair Lawn Ave.Fair Lawn, NJ 07410NO PHONE ENTRIES. NO FAX ENTRIES.NO EMAIL ENTRIES.NO REFUNDS.All athletes competing in two categories must fill out two formsContestant’s Last Name First Name Date of Birth:Address:City: State Zip Tel. #Judo Club: Rank:Card # (USA JUDO, USJA,USJF) Exp Date Age: Sex:Foreign Athlete Judo Passport # USA Citizen Yes No EmailDivision - Please check Division: (2.2 pounds 1kg) All athletes competing in two divisions must fill out two formsMasters Novice Women (White to Orange Belts): Age Group: 30 – 34 45 and over Weight kgs onlyMasters Women (All Ranks): Age Group: 30 – 34 45 and over Weight in kgs onlyMasters Novice Men (White to Orange Belts): Age Group: 30 – 39 40 – 49 50 and over Weight kgs onlyMasters Men (All Ranks): Age Group: 30 – 39 40 – 49 50 and over Weight kgs onlyIf player is uncontested in this division I authorize player to (check one):Move up next weight within same age groupMove up age group within same weightAccept uncontested medalI certify that all of the above information is correct.Signature: (Contestant 18 years or older or Parent/GuardianInstructor/Coach Certificate Regarding Contestants WeightI, , a judo instructor, who has been awarded the Judo rank ofName of InstructorShodan or higher, recognized by under the auspices of the USJI, USJF, USJA or Judo Canada, hereby certify that, is at the weight declared of in the above Entry Form.Name of contestantContestant’s weight in kilograms (Divide pounds by 2.2)I understand that if this player is not at the declared weight on the day of the tournament he/she may beremoved from competition and not allowed to participate.Judo Instructor (print)Signature of Judo Instructor

Certificate Regarding Non-Black belt ContestantsI, , a judo instructor, who has been awarded the Judo rank ofName of InstructorShodan or higher, recognized by under the auspices of the USJI, USJF, USJA or Judo Canada, hereby certifythat , although not having been awarded the Judo rank of Shodan orName of contestanthigher, is of sufficient aptitude and skill in Judo to compete in these Championships.A copy of my proof of rank (rank certificate or my USA JUDO membership card having the verification symbol“(V)” printed following my rank) is attached.Judo Instructor (print)Signature of Judo Instructor2014 Celita Schutz East Coast ChampionshipCredit Card Charge RequestIf you wish to use your Credit Card for Entry Fee, please complete the following information andenclose with your application form(s):Name:Billing Address Associated with Credit Card:Telephone #:Credit Card (circle one):MasterCardCreditCard #VISA///Credit Card Expiration DateCVV Code:(Month)(Year)Name of athlete if different from card holder:Name as it appears on Credit Card (please print):Amount authorized to charge: Signature: Date:

WARNING!WAIVER AND RELEASE OF LIABILITY AND AGREEMENT TO PARTICIPATE(Including Limited Co-Ed Competition for Age 8 and Under for USJI Sanction)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 JudoAssociation, Inc., United States Judo Federation, Inc., Hudson Judo Yudanshakai, Monsignor Farrell High School,Kokushiaki Judo Academy, Bushido Dojo of Staten Island, any Medical & Emergency Services Company andIndividuals, I agree:1. I understand the nature of Judo activities and believe I am qualified to participate in such Activity. I also understand therules governing the sport of Judo.2. I further acknowledge that prior to participating, I will inspect the mats, equipment, facilities, competition poolsor divisions, and the elimination or scoring system to be used, and if I believe anything is unsafe or beyond my capability,I will immediately advise my coach, supervisor, and/or a tournament 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 ordisease, including permanent disability or death, and severe social and economic losses due not only to my own actions, inactionsor negligence, but also to the actions, inactions, or negligence of others, the rules of the sport of Judo, or conditions of thepremises or of any equipment used. Further, I acknowledge that there may be other risks not known to me or not reasonablyforeseeable at this time.4. Knowing the risks involved in the sport of Judo, I assume all such risks and accept personal responsibility for thedamages 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 StatesJudo Association, Inc., United States Judo Federation, Inc., Hudson Judo Yudanshakai, Monsignor Farrell HighSchool, Kokushiaki Judo Academy, Bushido Dojo of Staten Island, any Medical & Emergency Services Companyand Individuals, together with their affiliated clubs, their respective administrators, directors, officers, agents, coaches, andother employees or volunteers of the organization, event officials, medical personnel, other participants, their parents, legalguardians, supervisors and coaches, sponsoring agencies, sponsors, advertisers, and if applicable, owners, lessors, and lessees ofpremises used in conducting the event, all of whom are hereinafter referred to as "Releasees", from any and all litigationexpenses, attorney fees, loss, liability, damage or costs on account of injury, illness, disease, including permanent disabilityand death or damage to property, caused or alleged to be caused in whole or in part by the negligent acts or omissions of theReleasees or otherwise to the fullest extent permitted by law.I HAVE READ THE ABOVE WARNING, WAIVER, AND RELEASE, UNDERSTAND THAT I HAVE GIVENUP SUBSTANTIAL RIGHTS BY SIGNING IT, AND KNOWING THIS, SIGN IT VOLUNTARILY ANDWITHOUT ANY INDUCEMENT OR ASSURANCE OF ANY NATURE. CONSISTENT WITH THE BY-LAWSOF USJF, THIS TOURNAMENT MAY INCLUDE CO-ED COMPETITION FOR AGES 10 AND UNDER INCOMPARABLE AGE/WEIGHT DIVISIONS WHERE THERE IS AN INSUFFICIENT NUMBER OF GIRLSFOR NON-CO-ED AGE/WEIGHT DIVISIONS. I HAVE READ AND UNDERSTAND THE TOURNAMENTANNOUNCEMENT CONCERNING THESE SPECIAL DIVISIONS. I AGREE TO PARTICIPATE KNOWINGTHE RISKS AND CONDITIONS INVOLVED AND DO SO ENTIRELY OF MY OWN FREE WILL. I AFFIRMTHAT I AM AT LEAST 18 YEARS OF AGE, OR, IF I AM UNDER 18 YEARS OF AGE, I HAVE OBTAINEDTHE REQUIRED CONSENT OF MY PARENT/LEGAL GUARDIAN AS EVIDENCED BY THEIRSIGNATURE BELOW. I INTEND THIS TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALLLIABILITY TO THE GREATEST EXTENT ALLOWED BY LAW AND AGREE THAT IF ANY PORTION OFTHIS AGREEMENT IS HELD TO BE INVALID THAT THE BALANCE, NOTWITHSTANDING SHALLCONTINUE IN FULL FORCE AND EFFECT.ParticipantParticipant’s SignatureDateFOR 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 tohis/her release, as provided above, of all the Releasees, and, for myself, my heirs, assigns, and next of kin, I release andagree to indemnify and hold harmless the Releasees from any and all liabilities incident to my minor child’s involvementor participation including litigation expenses, attorney fees, loss, liability, damage or costs which may incur as the resultof the minor child’s participation in these programs as provided above, even if arising from their negligence, to the fullestextent permitted by law. I have instructed the minor participant as to the above warnings and conditions and theirramifications.Parent/Legal GuardianParent/Legal Guardian’s SignatureDate

CSECC ENTRY REQUIREMENTS CHECKLISTTo assure that the requirements for participation in the Celita Schutz East Coast Championshiphave been fulfilled, thefollowing forms must be completed and sent to the address printed at thebottom of this page. Official Entry Form(s) and appropriate fees Copy of current USA JUDO, USJA or USJF membership card. Certificate Regarding Contestant’s Weight signed by Contestant’s Coach/Instructor Certificate for Non-Black Belt Contestants Signed Warning, Waiver, Release of Liability and Agreement to Participate Contestants & Parent/Guardian Signatures wherever requested on all documents Proof of Age: Copy of birth certificate, passport, or driver’s license.Attention:2014 Celita Schutz ECC24-28 Fair Lawn Ave.Fair Lawn, NJ 07410

Driving Directions to Monsignor Farrell High School:2900 Amboy Road, Staten Island, NY 10306From the NJ Turnpike:Take exit 13 (Elizabeth) to Goethals Bridge:Take the Staten Island Expressway (I278) Eastbound to Exit 12 (Todt Hill Rd.)At Stoplight turn right onto Slosson Avenue, Continue on Slosson Avenue/Todt Hill Road to end. Turnright onto Richmond Road. Continue on Richmond Road approximately 1.1 miles, take the fork to theleft onto Amboy Road, Proceed on Amboy Road to 2900. Venue will be on left.From Brooklyn/Verrazano Bridge:Take the Staten Island Expressway Westbound to exit 12 (Todt Hill Road)Turn Left onto Slosson Ave. Proceed as above.From the Garden State Parkway:Take exit 127 for NJ 440 towards I-287N, follow signs for NJ 440 N / Perth Amboy. Keep left at the forkand merge onto NJ 440 N. Continue on NJ 440 North to the Outerbridge Crossing.Take the Korean War Veterans Highway 8.2 miles to end. Proceed to Arthur KillRoad. Make Right turn on Arthur Kill road. At next traffic light turn right onto Richmond Avenue.Continue Approximately 2 miles on Richmond Avenue to Amboy Road. Turn Left on Amboy Road.Continue on Amboy road 2.8 miles to venue on LeftPublic Transportation to Monsignor Farrell High School: Ferry: Take Staten Island Ferry to Staten Island RapidTransit. Take SIRT to the Oakwood Station. Venue is directly behind the train station.NYC Transit Bus from Staten Island Ferry ramp D, take bus S55 to venue.Tournament Area Hotels:Hampton Inn1120 South AveStaten Island, NY 10314718-477-1600Comfort Inn310 Wild AveStaten Island, NY 10314718-370-8555Tournament Area Airports:(LGA) La Guardia Airport, NYC(JFK) John F. Kennedy Airport, NYC(EWR) Newark Airport, NJHilton Garden Inn1100 South AveStaten Island, NY 10314718-477-2400

Judo Tournament Date: Sunday . who has a CURRENT USA Judo, USJA or USJF Card or National Passport Card for foreign athletes. Judo players must present card at registration. A photocopy of your card/judo passport must be sent with your . 32, 37, 37 All ranks Boys 10-12 years old: 35, 42, 47, 50, 58, 58 All ranks Boys 13-14 years old: 42 .