The information on this form must be complete before submitting it. Signatures will be allowed to be submitted on the paper form you turn in at the tournament. You will be given an opportunity to print this form out.

Once the form is submitted any changes or modifications will be charged to the individual contestant.
The fields marked with * must be filled in before submitting the form.

First Name*

Last Name*

Address

City

ST/Prov

ZIP/Postal Code

Name of High School

Class of:*

Date of Birth

Sex:*

Weight Div Middle School*

Judo Rank

National Membership

Card Number

Academic Certification

Signature of School Official

Title

Present physical condition. (List all previous and current injuries that are not completely healed). Use a separate sheet, if necessary.

The above named person is a full-time student in good standing at the present time.

By signing I certify that the above infomation is complete and correct.

For Minor Participants only (under the age of 18)

I have reviewed the above infomation and certify that it is complete and correct.

Signature of Applicant

Date

Signature of Parent/Guardian

Date

NOTE: All portions of the application must be complete with proper signatures and sumitted along with eth liability waiver and entry fee before the entry deadline. Each contest must be accompanied by a respoinsible adult at the time of weigh-in and said person must be present at all competive events.

Name of Adult Supervisor:

E-Mail*

Weight Div High School*

You must click the submit button for the form to be sent.