Individual Waiver Form
2016 U.S. Capital Wushu Championships March 12, 2016
Organized by: Northern Virginia Wushu Academy
Form Due by February 12, 2016
Email: [email protected]
Or Mail to: NOVA Wushu Academy
14088 G Sullyfield Cir. Chantilly, VA 20151
LAST NAME: __________________________ FIRST: ___________________________ MI: _____________
STREET: ____________________________________________________________________________________
CITY: ___________________________ STATE: _______________ ZIP: ________________
PHONE (PRIMARY): _____________________ PHONE (ALTERNATE): _____________________
EMAIL: ______________________________________________________________________________________
DATE OF BIRTH: M / D / Y AGE: SEX (circle one): M F
YEARS EXPERIENCE:__________ SCHOOL:____________________________________
PRIMARY INSTRUCTOR:______________________________________
SCHOOL ADDRESS:___________________________________________________________
CITY:________________________ STATE:___________ ZIP:__________________
PHONE:____________________________ EMAIL:____________________________________
WAIVER I, the undersigned, knowingly and without duress, do voluntarily submit my entry to the 2016 U.S. Capital Wushu Championships (hereinafter referred to as “the Championships”). I hereby assume all risk of physical and mental injuries, disabilities, and losses which may result from or in connection with my participation in the Championships. Hereinafter the Northern Virginia Wushu Academy and Northern Virginia Community College are collectively referred to as “the Organizing Committee.” Acting for myself, my heirs, personal representatives and assignees, I do hereby release the Organizing Committee, its officers, agents, representatives, servants, employees, volunteers, and all other members from liability due to any injuries incurred and any resulting legal claims, actions, suits or controversies. I also understand that there is risk of injury involved in all the competitive divisions, particularly in fighting events, and I assume full responsibility for all my actions, activities or omissions during and in connection with the Championships. I fully understand that any medical attention or treatment afforded me by the Organizing Committee, its officers, agents, representatives, servants, employees, volunteers, and all other related members will be of the first aid type only, and I hereby release the Organizing Committee, its officers, agents, representatives, servants, employees, volunteers, and all other related members from any liability for such aid. I have read, understand, and agree to abide by the rules of this event, and accept all responsibility and associated liability for infringement of such rules. Additionally, I am fully aware of my personal medical condition and hereby certify that I am mentally and physically fit to compete. I consent to the use of photographs and/or video recordings of my participation in this event for promotional purposes, and hereby waive my rights to any form of compensation or claim.
Parent or legal guardian signature is required if participant is under eighteen (18) years of age.
________________
Signature of Participant Signature of Legal Guardian Date
Registration Form
2016 U.S. Capital Wushu Championships
Saturday, March 12, 2016 Important Registration Policies – Please read carefully!
1. At the sole discretion of the Organizing Committee, events may be combined or divided at any time prior to competition.
2. All registration forms must be filled out COMPLETELY and ACCURATELY. Both email address and phone numbers are REQUIRED.
3. All forms and payment must ARRIVE at NOVA Wushu Academy by mail or hand delivery on or before February 12, 2016.
4. Please note that all registration and event fees are non-refundable.
________________________________ ________________________________ ______/______/___________ First Name Last Name Birthday (mm/dd/yyyy) ________________________________ ________________________________ ________________________________________________ Email Phone School
Please complete the following steps and calculate your fees accordingly.
① Sex: Male Female
② Level of Experiences: (Please √ one – No separate experience level) Beginner (0-2 years) Intermediate (No more than 4 years) Advance
③ Age Group: (Please √ one)
Group 1: 6 years old and under, male or female, born in 2010 or later Group 2: 7-9 years old, male or female, born in 2009-2007 Group 3: 10-12 years old, male or female, born in 2006-2004 Group 4: 13-15 years old, male or female, born in 2003-2001 Group 5: 16-18 years old, male or female, born in 2000-1998 Group 6: 19-25 years old, male or female, born in 1997-1991 Group 7: 26-55 years old male or female, born in 1990-1961 Group 8: 56 years old & over, male or female, born before 1960
④ Events: (Please write event code in boxes **please see list of events**)
⑤ All-Around Champion: (Please √ one) All-Around Champion Group 1: 12 years old and under, male or female All-Around Champion Group 2: 13-18 years old, male or female All-Around Champion Group 3: 19-25 years old, male or female All-Around Champion Group 4: 26-55 years, male or female All-Around Champion Group 5: 56 years old and above, male or female
Early Registration Fees Quick Lookup (July 17th – Sept. 17th)
Unlimited Events: $90 All-Around: $30 Group Competition: $200 Team Competition: $125
Fees Quick Lookup (Sept. 18th – Feb. 12th)
1-2 Events: $90 3 Events: $110 4 Events: $130 5 Events: $150 All-Around: $30 Group Competition: $400 Team Competition: $250
⑥ Payment method: (To ensure payment credited correctly, please enclose a copy of the payment receipt if paid by credit card)
_____ Pay by Credit Card at www.uscapitalwushuchampionships.com
______ Check or Money Order: Please make your check or money order payable to: NOVA Wushu Academy.
⑦ Mail payment and completed registration, and waiver forms to: NOVA Wushu Academy, 14088 G Sullyfield Cir., Chantilly, VA 20151 (please reference participant’s name on the check)
Tournament Events * All “standard” forms are those established by IWuF. ** “Optional” forms are individual, self-created forms not established by IWuF. Nandu rules will be applied. *** “Optional Long Fist with Music” forms are individual, self-created forms not established by IWuF. Nandu rules will be applied.
Contempoary Wushu Hand Forms Traditional Long Weapons
1000 Elementary Long Fist (IWuF) * 1061 Traditional Staff
1001 Standard Long Fist (IWuF 1st set)* 1062 Traditional Southern Staff
1002 Standard Long Fist (IWuF 2nd set)* 1063 Other Traditional Staff
1003 Standard Long Fist (IWuF 3rd set)* 1064 Traditional Spear
1004 Other Long Fist 1065 Other Traditional Spear
1005 Optional Long Fist** 1066 Pudao
1006 Optional Long Fist with Music*** 1067 Traditional Kwandao
1007 Standard Southern Fist (IWuF 1st set)* 1068 Other Traditional Long Weapons
1008 Standard Southern Fist (IWuF 3rd set)* 1069 Traditional Soft Weapons
1009 Other Southern Fist 1070 Three-section Staff
1010 Optional Southern Fist ** 1071 9 Section Single Whip
Contemporary Wushu Short Weapons 1072 Double Whip or Whip with Sword
1011 Elementary Broad Sword (IWuF) 1073 Other Traditional Soft Weapons
1012 Other Broad Sword Taiji Hand Forms
1013 Standard Broad Sword (IWuF 1st set)* 1074 24 Taiji Quan
1014 Standard Broad Sword (IWuF 2nd set)* 1075 42 Taiji Quan
1015 Standard Broad Sword (IWuF 3rd set)* 1076 Yang Taijiquan
1016 Optional Broad Sword** 1077 Chen Taijiquan
1017 Standard Southern BroadSword (IWuF 1st set)* 1078 Wu Taijiquan
1018 Standard Southern BroadSword (IWuF 3rd set)* 1079 Sun Taijiquan
1019 Other Southern Broad Sword 1080 Wu haoTaijiquan
1020 Optional Southern Broad Sword** 1081 Mulanquan
1021 Elementary Straight Sword (IWuF)* 1082 Other Taiji Quan
1022 Other Straight Sword 1083 Optional Taiji Quan **
1023 Standard Straight Sword (IWuF 1st set)* Taiji Weapons
1024 Standard Straight Sword (IWuF 2nd set)* 1084 Yang Taiji Broad Sword
1025 Standard Straight Sword (IWuF 3rd set)* 1085 Chen Taiji Broad Sword
1026 Optional Straight Sword** 1086 Other Taiji Broad Sword
Contemporary Wushu Long Weapons 1087 Yang Taiji Straight Sword
1027 Elementary Staff (IWuF)* 1088 Chen Taiji Straight Sword
1028 Other Staff 1089 42 Taiji Straight Sword
1030 Standard Staff (IWuF 1st set)* 1090 Wudang Taiji Straight Sword
1031 Standard Staff (IWuF 2nd set)* 1091 Other Taiji Short Weapons
1032 Standard Staff (IWuF 3rd set)* 1092 Other Taiji Long Weapons
1033 Optional Staff** 1093 Optional Taiji Sword **
1034 Elementary Spear (IWuF)* Duilian
1035 Other Spear 1094 Wushu Barehand Duilian
1036 Standard Spear (IWuF 1st set)* 1095 Taiji Barehand Duilian
1037 Standard Spear (IWuF 2nd set)* 1096 Wushu Weapon Duilian
1038 Standard Spear (IWuF 3rd set)* 1097 Taiji Weapon Duilian
1039 Optional Spear** Group
1040 Other Southen Staff 1098 Group Kung Fu
1041 Standard Southen Staff (IWuF 1st set)* 1099 Group Chen Taiji
1042 Standard Southen Staff (IWuF 3rd set)* 1100 Group Yang Taiji
1043 Optional Southern Staff** 1101 Group Taiji Fan
Traditional Hand Forms 1102 Group Taiji Sword
1044 Traditional Northern Fist 1103 Group Health Qigong
1045 Traditional Southern Fist 1104 Other
1046 Other Traditional Fist Combined Team Competition (New)
1047 Xingyi, Bagua, Baji, Fanzi 1105 Optional Long Fist**
1048 Ditang, Pigua, Tongbei 1106 Optional Southern Fist **
1049 Chaquan, Huaquan,Paoquan 1107 Optional Broad Sword**
1050 XiangxingQuan (Animal Styles) 1108 Optional Straight Sword**
Traditional Short Weapons 1109 Optional Southern Broad Sword**
1051 Traditional Broadsword 1110 Optional Staff**
1052 Traditional Southern Broadsword 1111 Optional Spear**
1053 Other Traditional Broadsword 1112 Optional Southern Staff**
1054 Traditional Twin Broadsword 1113 Optional TaiJi Fist**
1055 Traditional Straight Sword 1114 Optional TaiJi Sword**
1056 Other Traditional Straight Sword
1057 Traditional Twin Straight Sword
1058 Other Traditional Single Short Weapon
1059 Other Traditional Twin Short Weapon
1060 Kung Fu Fan (Single/Twin)
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