2010 Registration is Closed
Online Registration Registering by mail
To register securely online please complete the following information in it's entirety and click "submit" at the bottom of the form. You will then be taken to the payment page for secure payment through "PayPal". Be sure to order your materials on the Materials Order page.
Competitor Info Name Male/Female Birth Date (Month/Day/Year) Age Name of Parent/Guardian if under 18 Street Address City State Country Zip Code Home Phone Cell Phone E-mail Years of training Rank/Style Weight (in lbs) Organization/Federation Association Emergency Contact Name Emergency Contact Relationship Emergency Contact Home Phone Emergency Contact Cell Phone Emergency Contact Work Phone Emergency Contact E-mail Studio Info Studio Name Head Instructor Studio Street Address Studio City Studio State Studio Zip Code Studio Phone Studio Website Divisions Entered Division Numbers Only First Time Breakers Creative Multi-Directional Wood Breaking Creative Open Breaking Power Concrete Hand Power Concrete Elbow Power Concrete Foot Speed Board Breaking High Jump Board Breaking Power Board Hand Power Board Elbow Power Board Foot Non-Spaced Power Board Hand Non-Spaced Power Board Elbow Total number of divisions entered I hereby submit my registration form to the 2010 PA State Breaking Championships. I agree to save & hold harmless USBA/WBA (USBA llc), Management, Sponsor, Spectrum Health and Racquet Club, their officers, agents, members & employees from any & all liability resulting from injuries to any person or for damages to or loss of property owned or controlled by me. I fully understand and shall adhere to all rules and regulations. I release all photo & video rights that may be used for publicity, promotion and/or media release without any form of compensation. Signature (Parent or Guardian if under 18): Your signature confirms that you have read and approve of the above release Your entry at right will act as your signature
Signature (Parent or Guardian if under 18):
Your signature confirms that you have read
and approve of the above release
Your entry at right will act as your signature
To register by mail please download the divisions, registration form, and material's order form above. Fill in the registration and materials order forms completely and return with payment to the address on the forms.
