Nanaimo Judo Club

Registration 2015/2016

Registration Date __________________________

Member Last Name_________________________________

Birth Date_____________ __________ __________

Member First Name_________________________________

(month)

(day)

(year)

Address__________________________________________________________________________________
City/Town__________________________________________ Postal Code_____________________________
Parent or Guardian's Names___________________________________________________________________________
Phone#____________________________________ E-mail_______________________________________
Cell#____________________________________
Member Medical#_________________________________

_______________________________________

Family Doctor_________________________________

Emergency Contact Person________________________________Phone#_____________________________________

Medical concerns (allergies, medications, disabilities etc..)________________________________________________
___________________________________________________________________________________________________
RELEASE: In consideration of the acceptance of this application for registration, I, tending to be legally bound
hereby for myself, my heirs, executors and administrators, waive and release any an all rights and claims for
damages I may have against the Nanaimo Judo Club or its representatives and/or assignees for any and all
damages which may arise out of my travelling to, participating in, or returning from Judo.
Signature (member/parent/guardian)___________________________________________________________________
Please print name______________________________________ Date Signed__________________________________
I agree that Nanaimo Judo Club can/may use my childs picture in various media: Facebook, web, print

OFFICE USE BELOW

Jr: U14 and under; Senior: U16 and over

WEIGHT:

RANK:

REGISTRATION FEES (Junior $61 (2003 or later) or Senior $76 (2002 or earlier) or Black Belt $81 (age 64 & earlier)
or $40.50 (age 65 & over) (circle fee amt.)
DATE PAID________________CHEQ & AMT_____________________CASH AMT_____________________

CLUB DUES (Junior $40/mnth, Intermediate $45/mnth, Senior $50/mnth, Family $70/mnth) (circle dues amt.)
Junior - 2003 or later; Intermediate - 2002 thru 1996; Senior 1995 and earlier
SEPT

DATE PAID________________CHEQ & AMT_____________________CASH AMT_____________________

OCT

DATE PAID________________CHEQ & AMT_____________________CASH AMT_____________________

NOV

DATE PAID________________CHEQ & AMT_____________________CASH AMT_____________________

DEC

DATE PAID________________CHEQ & AMT_____________________CASH AMT_____________________

JAN

DATE PAID________________CHEQ & AMT_____________________CASH AMT_____________________

FEB

DATE PAID________________CHEQ & AMT_____________________CASH AMT_____________________

MAR

DATE PAID________________CHEQ & AMT_____________________CASH AMT_____________________

APR

DATE PAID________________CHEQ & AMT_____________________CASH AMT_____________________

MAY

DATE PAID________________CHEQ & AMT_____________________CASH AMT_____________________

initial

OFFICE USE BELOW

TOURNAMENTS & FEES
TOURNAMENT LOCATION & DATE______________________________________________________________________
DATE PAID_____________________CHEQ & AMT_______________________CASH AMT_______________________
TOURNAMENT LOCATION & DATE______________________________________________________________________
DATE PAID_____________________CHEQ & AMT_______________________CASH AMT_______________________
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DATE PAID_____________________CHEQ & AMT_______________________CASH AMT_______________________
TOURNAMENT LOCATION & DATE______________________________________________________________________
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TOURNAMENT LOCATION & DATE______________________________________________________________________
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TOURNAMENT LOCATION & DATE______________________________________________________________________
DATE PAID_____________________CHEQ & AMT_______________________CASH AMT_______________________
TOURNAMENT LOCATION & DATE______________________________________________________________________
DATE PAID_____________________CHEQ & AMT_______________________CASH AMT_______________________
TOURNAMENT LOCATION & DATE______________________________________________________________________
DATE PAID_____________________CHEQ & AMT_______________________CASH AMT_______________________
TOURNAMENT LOCATION & DATE______________________________________________________________________
DATE PAID_____________________CHEQ & AMT_______________________CASH AMT_______________________
TOURNAMENT LOCATION & DATE______________________________________________________________________
DATE PAID_____________________CHEQ & AMT_______________________CASH AMT_______________________
TOURNAMENT LOCATION & DATE______________________________________________________________________
DATE PAID_____________________CHEQ & AMT_______________________CASH AMT_______________________
TOURNAMENT LOCATION & DATE______________________________________________________________________
DATE PAID_____________________CHEQ & AMT_______________________CASH AMT_______________________
TOURNAMENT LOCATION & DATE______________________________________________________________________
DATE PAID_____________________CHEQ & AMT_______________________CASH AMT_______________________
TOURNAMENT LOCATION & DATE______________________________________________________________________
DATE PAID_____________________CHEQ & AMT_______________________CASH AMT_______________________
TOURNAMENT LOCATION & DATE______________________________________________________________________
DATE PAID_____________________CHEQ & AMT_______________________CASH AMT_______________________