REGISTRATION FORM

The Undersigned below,
Contingent / Institution / Perguruan : …………………………………………………………
: ………………………………………………………....

Address

…………………………………………………………

Are registering to attend and joint The International Pencak Silat Championship 2015 Earlyaged / Pre-Teenagers / Teenagers / Adults Level with a team that consists of:

A. OFFICIAL
a. Team Manager

: ……………………………………………..…………………..

b. Coach

: 1. ……………………………………………………………....
2. ………………………………………....................................

B. ATHLETES
The list of our athletes will be listed of the attachment.

The completion of administration submits at:
1. With this Registration Form*
2. The latest at ………………………………………….*
*) choose one

……………………………………., ……/……/2016
Contingent/Perguruan …………………………………
Official/Team Manager

___________________
(Full Name)

REGISTRATION FORM
EARLY-AGE / PRE-TEENAGERS / TEENAGERS / ADULTS CATEGORY*

Contingent / Perguruan : …………………………………………….

MALE

WEIGHT
CLASS

FEMALE

A
B
C
D
E
F
G
H
I
J

MALE

SENI
CATEGORY
TUNGGAL
GANDA

BEREGU

*) Choose one

FEMALE

ATHLETE’S DATA
CATEGORY

: Early-Age / Pre-Teenagers / Teenagers / Adults*

Full Name

: ………………………………………………………………….

Sex

: Male / Female*

Place and Date of Birth : ………………, …………………..19….
: ………………………………………………………………………

Address

………………………………………………………………………
………………………………………………………………………
Height, Weight

: ………… cm, …………….kg

Blood Type

: A / B / O / AB*

Contingent / Perguruan : ………………………………………………………………………

Will be join The International Pencak Silat Championship FIGHTING Category in weight
class:

A

B

C

D

E

MALE

F

G

H

I

J

FEMALE

*)choose one
PASSPORT PHOTO

4X6

3X4

3X4

4X6

………………………………….. , ………………………….2016
Contingent / Perguruan …………………………….
Official / Team Manager

……………………………..
Can be copied as much as needed

ATHLETE’S DATA
CATEGORY

: Early-Age / Pre-Teenagers / Teenagers / Adults*

Full Name

: ………………………………………………………………….

Sex

: Male / Female*

Place and Date of Birth : ………………, …………………..19….
: ………………………………………………………………………

Address

………………………………………………………………………
………………………………………………………………………
Height, Weight

: ………… cm, …………….kg

Blood Type

: A / B / O / AB*

Contingent / Perguruan : ………………………………………………………………………

Will be join The International Pencak Silat Championship SENI IPSI in category:

T

MALE

R

G

FEMALE
*)choose one
PASSPORT PHOTO

4X6

3X4

3X4

4X6

………………………………….. , ………………………….2016
Contingent / Perguruan …………………………….
Official / Team Manager

……………………………..
Can be copied as much as needed

LETTER OF RECOGNITION
The Undersigned below,

Name

: ………………………………………………………………………..

Position / Occupation : ………………………………………………………………………..
States that our Perguruan Pencak Silat …………………………………………………………
is registered in …………………………………………………………………… Pencak Silat
Associations with registration number: ………………………………………………………

With this letter I guarantee that my statement above is true and correct. If there are
any matters or problems related to this letter, I would like to take all of the responsibilities
and consequences that occur.
………………………., ……..2016

(……………………………………….)
Full Name

Can be copied as much as needed

COMPUTER USE AND PROMOTIONAL MEDIA AGREEMENT
I

: ___________________________________________________________________
(Full name)

Of

: ___________________________________________________________________
(Contingent/perguruan name)

1. Consent to video footage/photos/other images of myself being taken at the International
Pencak Silat Championship 2016 hosted by Al Azhar Seni Bela Diri Indonesia for
publications, promotional material, websites and advertisements, for an undefined period of
time

2. Understand that any video footage/photos/other images taken at the International Pencak
Silat Championship 2016 may be shown in a public environment (in Jakarta, interprovincial
and/or overseas)

3. Acknowledge that there is to be no payment or further consideration paid for my
performance

4. Not access or communicate any profane, offensive, pornographic or obscene material
trough hotel’s Wi-Fi and computers

5. respect and take care with all computing and AV equipment

Signed by: _________________________________________ Date : ___________________

Can be copied as much as needed

PARENTS CONCERNED LETTER
The undersigned below,

Name

: …………………………………………………………………………

Occupation

: …………………………………………………………………………

Cellphone Number

: …………………………………………………………………………

Status

: Father / Mother / Others: ……………….. (choose one)

Is giving my permission to my child,

Name

: ………………………………………………………………………

Born Place and Date

: ………………………………………………………………………

Sex

: ………………………………………………………………………

Contingent/Perguruan

: ………………………………………………………………………

To attend and join International Pencak Silat Championship 2016 hosted by Al Azhar Seni
Bela Diri on May 5th-7th 2016 in Padepokan Pencak Silat TMII Jakarta, Indonesia. With this
letter we state our support this event and would not sue championship’s committee or coach
to any authorities institutions if something happened to my child (injury) caused by the
championship after the medical treatments was given by doctors or any other apparatus that
authorized by in the championship.

This letter we sign for the right use.
………………………………….,…………2016

(……………………………………………..)
Parent’s full name

Can be copied as much as needed

PERSONAL CONCERNED LETTER
The undersigned below,

Name

: ………………………………………………………………………

Born Place and Date

: ………………………………………………………………………

Sex

: ………………………………………………………………………

Contingent/Perguruan

: ………………………………………………………………………

Is willing to attend and join International Pencak Silat Championship 2016 hosted by Al
Azhar Seni Bela Diri on May 5th-7th 2016 in Padepokan Pencak Silat TMII Jakarta,
Indonesia. With this letter I state my support this event and would not sue championship’s
committee or coach to any authorities institutions if something happened to myself (injury)
caused by the championship after the medical treatments was given by doctors or any other
apparatus that authorized by in the championship.

This letter we sign for the right use.
………………………………….,…………2016

(……………………………………………..)
Athlete’s full name

Can be copied as much as needed

TEAM DATA
Contingent/Perguruan

: …………………………………………………………………..

Address

: ……………………………………………………………………

NO

NAME

OCCUPATION/POSITION

Can be copied as much as needed

Note:
1. Team Data Forms contain all of the people that will attend the International Pencak
Silat Championship 2016 including non-athletes (coaches, officials, parents, etc.)
2. In the occupation/position column please write down your position on the team
(coaches, officials, athletes, parents, etc.)
3. The registration fee paid based on the number of people listed on the team data form
4. Any unlisted person would not be provided any facilities from the championship
committee