2011 ATU Midwest Regional Championship

Competitor Registration Form

* Required Fields

Competitor's Name * First Last
Parent or Guardian's Name (Required if Competitor is a Minor) First Last
Competitor's Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Competitor's Phone * - (###) - ### ####
Competitor's Email
Competitor's Date of Birth * / MM / DD YYYY
Competitor's Gender * Male Female
Competitor's Belt Rank *
Instructor
School/Club Name *
School/Club Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
School/Club Phone * - (###) - ### ####
Events

Paid Registration By 02/19/2011 Paid Registration After 02/19/2011

1 Event $60.00 $70.00

2 Events $70.00 $80.00

3 Events $80.00 $90.00

4 Events $90.00 $100.00

Forms Breaking Sparring Team Forms
If competing in BREAKING: Number of boards needed:
Board fee: 1 Board = $3.00 2 Boards = $5.00 Number of Thick Breaking Boards
Number of Thin Breaking Boards
Number of Little Dragon Breaking Boards

Order Spectator Tickets

Number of Adult Tickets