Registration- 2009 USBA/UTA Pennsylvania Breaking Championships

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". You will also be able to order your materials and spectator tickets from the payment 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 Breaker or Creative Multi-Directional Wood Breaking
Creative Open Breaking
Power Concrete Hand
Power Concrete Elbow
Power Concrete Foot
Power Board Hand
Power Board Elbow
Power Board Foot- Kids Only
Total number of divisions entered
I hereby submit my registration form to the 2009 USBA/UTA Pennsylvania Breaking Championships. I agree to save & hold harmless USBA/WBA (USBA llc), Management, Sponsor, UTA Karate Dalton, 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