Registration

Fill out your information below.

Team/School (required)

Instructor (required)

Competitor First Name (required)

Competitor Last Name (required)

Address (required)

City (required)

State (required)

Zip Code (required)

Phone (required)

Weight (with Gi On) (required)

Birth Date (ex: 05/11/1985) (required)

Sex (required)

Belt Rank (required)

Emergency Contact Person (Name)

Emergency Contact Phone

Payer Name (required) The payer name will be the first and last name on your PayPal account.

Email Address (required)

How did you hear about us?

I, the competitor and/or parent or legal guardian, understand that by entering this competition it may entail some risk of accident or injury and that this risk may be serious or even fatal. I further understand that along with the possibility of personal injury that injury to property is also possible, such as but not limited to possible loss of wages and the ability to earn such. With full knowledge of the aforementioned dangers both to my person and to my property (current and future), I forever release and agree to hold harmless Pennsylvania State Brazilian Jiu-Jitsu Federation, Rogerio Taborda, and each of their agents, employees and representatives of and from all claims, demands, rights and causes of action of any nature whatsoever which I may have or which may hereafter accrue to me, arising from and by any reason of any and all bodily or personal injury, damage to property or other loss, and any consequences thereof, whether known or unknown, seen or unforeseen, resulting from my participation in this competition, the persons and entities mentioned above. I further understand that tickets will be sold to spectators to watch the tournament, that news media and others might cover the tournament and that it may also be photographed or videotaped or otherwise shown to audiences around the world. I hereby consent to having my likeness shown, publicized, commented and/or reported on, and I do not expect to and, in fact, waive any compensation I might otherwise be entitled to as a result thereof.

Competitor or Legal Guardian Electronic Signature (required)
(Parent or Legal Guardian must sign if competitor is under 18)

Type your full name in the box above. This serves as your legally binding signature.

After you click send wait for the form to be sent, then click on the Pay Now button below to be directed to PayPal for payment.