Individual Waiver Form 2017 U.S. Capital Wushu Championships March 11, 2017 Organized by: Northern Virginia Wushu Academy Form Due by February 10, 2017 Email: [email protected]Or Mail to: NOVA Wushu Academy 14088 G Sullyfield Cir. Chantilly, VA 20151 LAST NAME: __________________________ FIRST: ___________________________ MI: _____________ STREET: ____________________________________________________________________________________ CITY: ___________________________ STATE: _______________ ZIP: ________________ PHONE (PRIMARY): _____________________ PHONE (ALTERNATE): _____________________ EMAIL: ______________________________________________________________________________________ DATE OF BIRTH: M / D / Y AGE: SEX (circle one): M F YEARS EXPERIENCE:__________ SCHOOL:____________________________________ PRIMARY INSTRUCTOR:______________________________________ SCHOOL ADDRESS:___________________________________________________________ CITY:________________________ STATE:___________ ZIP:__________________ PHONE:____________________________ EMAIL:____________________________________ WAIVER I, the undersigned, knowingly and without duress, do voluntarily submit my entry to the 2016 U.S. Capital Wushu Championships (hereinafter referred to as “the Championships”). I hereby assume all risk of physical and mental injuries, disabilities, and losses which may result from or in connection with my participation in the Championships. Hereinafter the Northern Virginia Wushu Academy and NOVA Field House LLC are collectively referred to as “the Organizing Committee.” Acting for myself, my heirs, personal representatives and assignees, I do hereby release the Organizing Committee, its officers, agents, representatives, servants, employees, volunteers, and all other members from liability due to any injuries incurred and any resulting legal claims, actions, suits or controversies. I also understand that there is risk of injury involved in all the competitive divisions, particularly in fighting events, and I assume full responsibility for all my actions, activities or omissions during and in connection with the Championships. I fully understand that any medical attention or treatment afforded me by the Organizing Committee, its officers, agents, representatives, servants, employees, volunteers, and all other related members will be of the first aid type only, and I hereby release the Organizing Committee, its officers, agents, representatives, servants, employees, volunteers, and all other related members from any liability for such aid. I have read, understand, and agree to abide by the rules of this event, and accept all responsibility and associated liability for infringement of such rules. Additionally, I am fully aware of my personal medical condition and hereby certify that I am mentally and physically fit to compete. I consent to the use of photographs and/or video recordings of my participation in this event for promotional purposes, and hereby waive my rights to any form of compensation or claim. Parent or legal guardian signature is required if participant is under eighteen (18) years of age. ________________ Signature of Participant Signature of Legal Guardian Date
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Individual Waiver Form
2017 U.S. Capital Wushu Championships March 11, 2017
WAIVER I, the undersigned, knowingly and without duress, do voluntarily submit my entry to the 2016 U.S. Capital Wushu Championships (hereinafter referred to as “the Championships”). I hereby assume all risk of physical and mental injuries, disabilities, and losses which may result from or in connection with my participation in the Championships. Hereinafter the Northern Virginia Wushu Academy and NOVA Field House LLC are collectively referred to as “the Organizing Committee.” Acting for myself, my heirs, personal representatives and assignees, I do hereby release the Organizing Committee, its officers, agents, representatives, servants, employees, volunteers, and all other members from liability due to any injuries incurred and any resulting legal claims, actions, suits or controversies. I also understand that there is risk of injury involved in all the competitive divisions, particularly in fighting events, and I assume full responsibility for all my actions, activities or omissions during and in connection with the Championships. I fully understand that any medical attention or treatment afforded me by the Organizing Committee, its officers, agents, representatives, servants, employees, volunteers, and all other related members will be of the first aid type only, and I hereby release the Organizing Committee, its officers, agents, representatives, servants, employees, volunteers, and all other related members from any liability for such aid. I have read, understand, and agree to abide by the rules of this event, and accept all responsibility and associated liability for infringement of such rules. Additionally, I am fully aware of my personal medical condition and hereby certify that I am mentally and physically fit to compete. I consent to the use of photographs and/or video recordings of my participation in this event for promotional purposes, and hereby waive my rights to any form of compensation or claim.
Parent or legal guardian signature is required if participant is under eighteen (18) years of age.
________________
Signature of Participant Signature of Legal Guardian Date
Registration Form
2017 U.S. Capital Wushu Championships
Saturday, March 11, 2017 Important Registration Policies – Please read carefully!
1. At the sole discretion of the Organizing Committee, events may be combined or divided at any time prior to competition.
2. All registration forms must be filled out COMPLETELY and ACCURATELY. Both email address and phone numbers are REQUIRED.
3. All forms and payment must ARRIVE at NOVA Wushu Academy by mail or hand delivery on or before February 10, 2016.
4. NO REFUNDS. Please note that all registration and event fees are non-refundable. If a competitor cannot compete due to a medical reason, a doctor’s letter must be provided. Credit will be applied to the following year’s competition.
________________________________ ________________________________ ______/______/___________ First Name Last Name Birthday (mm/dd/yyyy) ________________________________ ________________________________ ________________________________________________ Email Phone School
Please complete the following steps and calculate your fees accordingly.
① Sex: Male Female
② Level of Experiences: (Please √ one – No separate experience level) Beginner (0-2 years) Intermediate (No more than 4 years) Advance
③ Age Group: (Please √ one)
Group 1: 6 years old and under, male or female Group 2: 7-9 years old, male or female Group 3: 10-12 years old, male or female Group 4: 13-15 years old, male or female Group 5: 16-18 years old, male or female Group 6: 19-25 years old, male or female Group 7: 26-55 years old male or female Group 8: 56 years old & over, male or female
④ Events: (Please write event code in boxes **please see list of events**)
⑤ All-Around Champion: (Please √ one) All-Around Champion Group 1: 12 years old and under, male or female All-Around Champion Group 2: 13-18 years old, male or female All-Around Champion Group 3: 19-25 years old, male or female All-Around Champion Group 4: 26-55 years, male or female All-Around Champion Group 5: 56 years old and above, male or female ⑥ USAWKF National Traditional Team Qualification: (Please √ one) 2017 USAWKF National Traditional Team Qualifier
Early Registration Fees Quick Lookup
(Sept. 3rd , 2016– Nov. 4th, 2016) Up to 4 Events: $90 5 Events: $110 All-Around: $30 Traditional Team Qualifier: $30 Group Competition: $200 Team Competition: $125
1-2 Events: $90 3 Events: $110 4 Events: $130 5 Events: $150 All-Around: $30 Traditional Team Qualifier: $30 Group Competition: $400 Team Competition: $250
⑦ Payment method: (To ensure payment credited correctly, please enclose a copy of the payment receipt if paid by credit card)
_____ Pay by Credit Card at www.uscapitalwushuchampionships.com
______ Check or Money Order: Please make your check or money order payable to: NOVA Wushu Academy.
⑧ Mail payment and completed registration, and waiver forms to: NOVA Wushu Academy, 14088 G Sullyfield Cir., Chantilly, VA 20151 (please reference participant’s name on the check)
Tournament Events * All “standard” forms are those established by IWuF. ** “Optional” forms are individual, self-created forms not established by IWuF. Nandu rules will be applied. *** “Optional Long Fist with Music” forms are individual, self-created forms not established by IWuF. Nandu rules will be applied.
Contempoary Wushu Hand Forms Traditional Long Weapons
1000 Elementary Long Fist (IWuF) * 1061 Traditional Staff
1001 Standard Long Fist (IWuF 1st set)* 1062 Traditional Southern Staff
1002 Standard Long Fist (IWuF 2nd set)* 1063 Other Traditional Staff
1003 Standard Long Fist (IWuF 3rd set)* 1064 Traditional Spear
1004 Other Long Fist 1065 Other Traditional Spear
1005 Optional Long Fist** 1066 Pudao
1006 Optional Long Fist with Music*** 1067 Traditional Kwandao
1007 Standard Southern Fist (IWuF 1st set)* 1068 Other Traditional Long Weapons
1008 Standard Southern Fist (IWuF 3rd set)* 1069 Traditional Soft Weapons
1009 Other Southern Fist 1070 Three-section Staff
1010 Optional Southern Fist ** 1071 9 Section Single Whip
Contemporary Wushu Short Weapons 1072 Double Whip or Whip with Sword
1011 Elementary Broad Sword (IWuF) 1073 Other Traditional Soft Weapons
1012 Other Broad Sword Taiji Hand Forms
1013 Standard Broad Sword (IWuF 1st set)* 1074 24 Taiji Quan
1014 Standard Broad Sword (IWuF 2nd set)* 1075 42 Taiji Quan
1015 Standard Broad Sword (IWuF 3rd set)* 1076 Yang Taijiquan
1016 Optional Broad Sword** 1077 Chen Taijiquan
1017 Standard Southern BroadSword (IWuF 1st set)* 1078 Wu Taijiquan
1018 Standard Southern BroadSword (IWuF 3rd set)* 1079 Sun Taijiquan
1019 Other Southern Broad Sword 1080 Wu haoTaijiquan