san shou league

* Mid America San Shou League

MID-AMERICA SAN SHOU LEAGUE

ENROLLMENT APPLICATION

[Please print]

Applying for classification as: Fighter ___ Coach ___ Side Judge ___ Referee ___

(enclose $35 registration fee)

Full Name: _______________________________________________ Birth Date: ____________ Age: _____________

Address: _________________________________________ City: ___________ State: ____ Zip: _______________

Telephone: (Cell) ______________________ (Home) _____________________ (Work) _____________________

Sex: (M) ____ (F) ____ Weight: __________ Height: feet inches

Insurance Carrier Name (fighters): _______________________________ Phone ( ) _____ - _________

Employer: _______________________________________ Job Title _________________________________________

Address: _________________________________________ City: ___________ State: ____ Zip: ________________

Martial Arts Experience

Style: ____________________________ Instructor/Coach: _____________________________ Years: ______ Months: ______

Address _____________________________________________ City ____________________ State ____ Zip _________

Style: ____________________________ Instructor/Coach: _____________________________ Years: ______ Months: ______

Address _____________________________________________ City ____________________ State ____ Zip _________

Style: ____________________________ Instructor/Coach: _____________________________ Years: ______ Months: ______

Address _____________________________________________ City ____________________ State ____ Zip _________

If under 18 years of age, parent or guardian's name: ________________________________________________________

MASSL AGREEMENT

I, ________________________________, the undersigned, agree to abide by the CUSTOMS & RULES of the Mid-America San

Print Name

Shou (San Da) League, herein after referred to as MASSL. I accept the responsibility for learning the CUSTOMS & RULES of the MASSL and to diligently abide by them. I, hereby, acknowledge that I am fully aware of the risk of physical injury involved in the learning, practice and/or participation of San Shou (San Da) events and competitions. I assume all such risks of injury, from any cause, while attending and/or participating in MASSL events or training provided by the MASSL or while representing the MASSL during demonstrations, public appearances, competitions, etc. Should I be injured, the MASSL or any of it's members/employees shall not be liable to pay the undersigned, or the undersigned's insurance carrier, hospitals, doctors, agents or any other person(s) any cost or compensation related to the injury.

If the applicant is under the age of 18, this AGREEMENT must be signed by a parent or guardian who has read and fully understands the terms and conditions of this AGREEMENT.

Student's Signature: _____________________________________ Date: __________

Parent/Guardian Signature: _______________________________ Date: ___________

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Mid-America San Shou League (MASSL)

Member Benefits

Fighters