2012 USA World Qualifier Registration

Each competitor must register separately.  Then click here to register a group of competitors for Team Patterns.

The deadline for registration was February 1, 2012.  There will be no late registration.

Your registration is not complete until all fees and waiver forms are received by Junbi Now.  You will receive a confirmation email once your registration is finalized.

On the form below, asterisks (*) indicate required fields.

* First Name

* Last Name

* Address

* City

* Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

* ZIP Code

* Phone #

* Email Address

* Age

* Gender

Male

Female

* Height

* Weight

* Your Instructor's Name

* Your School's Name

* Emergency Contact Name

* Emergency Contact Phone#

* Division

Junior

Adult

Senior

* Events

Patterns

Sparring

Power Breaking

Specialty Breaking

Team Patterns

* Rank 1st Dan 2nd Dan 3rd Dan 4th Dan 5th Dan 6th Dan

* ITF Certificate #

* Black Belt Status Card #

* Black Belt Status Card Expires

* Participation

USA World Qualifier only

Package A - USA World Qualifier and the Master Class

Name of another competing Family Member

* I will attend the Banquet

Yes

No

Additional Banquet Guests

* I will be coaching another competitor

Yes

No

Comments

* Type the numbers.