2022 US Open Championship JUNIORS ONLY

(DO NOT USE for Golden Score Event, Veterans or Senior Tournament)
OFFICIAL ENTRY FORM
16131 N.W. 12 Street; Pembroke Pines, FL 33028
Last Name (Family Name, Surname): First Name:
A M B U L U D I || S A M A N T H A
Street Address:
M A R I A N O E S T R E L L A
City: State Zip Code:
A Z U A Y || 0 7 || 5 9 3
Country:
E C U A D O R
Judo Club:
T E A M P R A D O J U D O
Coach’s Name:
O S C A R P R A D O
Telephone (Voice) (MANDATORY): Fax:
0 9 9 - 9 4 8 - 1 2 1 2 || - -
USA Judo, USJF, USJA or ATJA Member Number (US Athletes**): Date of Birth (month/day/year):
|| / /
Email Address (MANDATORY):
o s c a r _ p r a d o j u @ h o t m a i l . c o M
2022 US Open Championship JUNIORS ONLY!
Circle the category and gender in which you wish to compete. Circle One Category only!
If competing in more than 1 category, submit a separate entry form and fee for each category.
Enter estimated weight in kilograms. Note that this is a preliminary declaration of weight. The athlete’s measured weight
at weigh-in will determine the competition division.
Bantam-1 Bantam-2 Bantam-3 Bantam-4 Bantam-5 Bantam-6 Intermediate
Born 2017 Born 2016 (2017) Born 2015 (2016) Born 2014 (2015) Born 2013 (2014) Born 2012 (2013) Born 2010-2011 (2012)
Juvenile Cadet IJF Junior (Year of birth) of younger
Born 2008-2009 (2010) Born 2005-2007 (2008) Born 2002-2007 (2008) athletes who move up in age.

Circle Championship or Novice. If novice, provide belt color. DO NOT

Circle one: circle novice if you do not meet the qualifications on Page 14. Estimated wt.(kg):
Male Female Championship Novice Belt Color: YELLOW 25
U. S. Citizens having questions regarding eligibility should contact Mr. Gerry Navarro; Chairman, USA Judo’s Junior
Development Program via email: Gerrynavarro@aol.com
Please mail the appropriate entry fee (refer to page 6) payable to 2022 U.S. Open Judo Championship or add fee to
credit card charge request form, this entry form and all other documents, fully completed and signed in the
appropriate places, to Melinda Navarro at the address listed at the top of this entry form. A complete checklist
of required documents is printed elsewhere in this entry package. .DO NOT MAIL ANYTHING AFTER July 9, 2022.
After that date, bring entry materials to tournament registration on July 27 OR July 28 and register as a
“walk-up”. IMPORTANT! Do not forget to include proof of age (birth certificate or passport; a driver’s license is
NOT acceptable), proof of rank, and signature of parent/guardian if under 18 years of age. These items can be very
difficult to obtain, once you arrive at the event.

2022_US_Open_Juniors, Seniors, Veterans; Version #2, May 15, 2022 Page 1

 11 JUNIOR GOLDEN SCORE EVENT–SPECIFIC INFORMATION
On Sunday, July 31, in order to provide more matches for the athletes and excitement for all,
there will be a new-style tournament IN ADDITION to the normal age-weight divisions.
The Golden Score Tournament IS NOT a USA Judo point event but counts for the
total Gold medal count for the team award grant.
Registration: Athletes may register during the Wednesday-Thursday registration periods or on Saturday during
the same time period allotted for Senior and Veteran registration.
Entry fee: Please refer to the schedule of fees and deadlines on page 6.
Weigh-in: There will be no weigh-in. Weights used will be the athlete’s weight for the regular US Open Junior
Championship.
Eligibility: Athletes MUST COMPETE in the Junior Championship of the. U.S. Open Judo Championship in
order to be eligible for the Golden Score Tournament.
Awards: Medals to 1st, 2nd & 3rd place winners
Competition Categories:
Categories Weights
Same as for the Championship Light Medium Heavy

JUNIOR GOLDEN SCORE METHOD OF COMPETITION, RULES AND POINTS

Elimination Systems: Round Robin for divisions of 5 or fewer; Modified Double Elimination for all others.
Refer to Page 9 for complete details of these elimination systems.
Rules:
1. First one to score wins.
2. Time Limits: 5 minutes for Bantam-1, Bantam-2, Bantam-3 Categories; No time limits for all other
Categories.
Eligibility:
Athletes MUST COMPETE in the Junior Championship of the. U.S. Open Judo Championship in order to be
eligible for the Golden Score Tournament.
The Golden Score Tournament IS NOT a USA Judo point event, but medals won
WILL count for the $1,000 team award grant.

2022_US_Open_Juniors, Seniors, Veterans; Version #2, May 15, 2022 Page 2

 JUNIOR GOLDEN SCORE TOURNAMENT
(DO NOT USE for Junior Championship, Veterans or Senior Tournament)
OFFICIAL ENTRY FORM
16131 N.W. 12 Street; Pembroke Pines, FL 33028
Last Name (Family Name, Surname): First Name:
||
Street Address:

City:: State Zip Code:

|| ||
Country:

Judo Club:

Coach’s Name:

Telephone (Voice) (MANDATORY): Fax:

- - || - -
USA Judo, USJF, USJA or ATJA Member Number (US Athletes**): Date of Birth (month/day/year):
|| / /

JUNIOR GOLDEN SCORE TOURNAMENT ONLY!

Circle the category in which you wish to compete. Circle One Category only!
Bantam-1 Bantam-2 Bantam-3 Bantam-4 Bantam-5 Bantam-6
Born 2017 Born 2016 Born 2015 Born 2014 Born 2013 Born 2012
Intermediate Juvenile Cadet IJF Junior
Born 2010-2011 Born 2008-2009 Born 2005-2007 Born 2002-2007

Circle One:
Male Female

Please mail the appropriate entry fee (refer to page 6) payable to 2022 U.S. Open Judo Championship or add fee to credit card
charge request form, this entry form and all other documents, fully completed and signed in the appropriate places, to Melinda
Navarro at the address listed at the top of this entry form. Athletes MUST compete in the Junior Championship in order
to be eligible to compete in the Golden Score Tournament. DO NOT send in this entry form unless you register
for the Championship!!

** US Citizens: If you are not a current member of USA Judo, USJF, USJA or ATJA please circle:
Will bring current membership card to event Will purchase membership at event

2022_US_Open_Juniors, Seniors, Veterans; Version #2, May 15, 2022 Page 3

 14 WAIVERS
FALSE ALARM/DAMAGES
This form certifies that the Contestant and her/his legal guardian(s) understand that emergency vehicle response to a false alarm may result in serious injury
and loss of life, and that fine, imprisonment and other possible legal consequences may result from activating any false alarm in connection with participation
in this tournament. In addition, charges assessed for a false alarm or for other damage to tournament and hotel facilities shall, together with all costs and fees
incurred with collecting said charges, shall be the responsibility of the responsible Contestant’s parent(s) /legal guardian(s) and home Dojo. This provision
has been explained to the Contestant.
SAMANTHA AMBULIDI 11/06/2022

Contestant's Printed Name Contestant's Signature Date

ANA SINCHI 11/06/2022

Parent/Guardian's Printed Name Parent/Guardian's Signature Date

OSCAR PRADO 11/06/2022

Judo Instructor's Printed Name Judo Instructor's Signature Date

WAIVER AND RELEASE OF LIABILITY AND AGREEMENT TO PARTICIPATE
In consideration of being permitted to participate in any way, including travel to and from, the 2022 US OPEN Judo Championships and related events and
activities of United States Judo, Inc. (USA Judo), USJA, USJF, ATJA, Greater Fort Lauderdale/Broward County Convention Center, Marriott Harbor Beach Resort
and Spa, Best Western Plus Ocean Side, B Ocean Resort, Tournament Directors, Tournament Organizers, Tournament Staff, Florida Judo, Inc. and YMCA Panther
Judo, I hereby:
1. Acknowledge that I am familiar with the sport of Judo and understand the rules governing the sport of Judo.
2. Agree that prior to participating, I will inspect the mats, equipment, facilities, competition pools or divisions and the elimination or scoring system to be
used, and if I believe anything is unsafe or beyond my capability, I will immediately advise my coach, supervisor, and/or a tournament official of such
conditions and refuse to participate.
3. Acknowledge and fully understand that I will be engaging in a contact sport that might result in serious injury, including permanent disability or death,
including possible exposure to and illness from infectious diseases (including but not limited to COVID-19, and severe social and economic losses due to not
only my own actions, inactions, or negligence, but also to the actions, inactions, or negligence of others, the rules of the sport of Judo, or conditions of the
premises or of any equipment used. Further, I acknowledge that there may be other risks not known to me or not reasonably foreseeable at this time.
4. Knowing the risks involved in the sport of Judo, I assume all such risks and accept personal responsibility for the damages caused by, arising out of,
resulting from or following such injury, permanent disability, or death. I understand that should I elect for myself or my child to participate in a weight or age
category outside of his/her “true” weight/age and/or in a category with a significant weight disparity, that the risk of injury, permanent disability or death
could be increased.
5. Release, waive, discharge and covenant not to sue the United States Judo, Inc., the United States Olympic & Paralympic Committee, United States Judo
Federation, United States Judo Association, American Traditional Jujutsu Association, Greater Fort Lauderdale Broward County Convention Center, Marriott
Harbor Beach Resort and Spa, Best Western Plus Ocean Side , B Ocean Resort, Tournament Directors, Tournament Organizers, Tournament Staff, Florida Judo,
Inc., YMCA Panther Judo, together with their affiliated clubs, their respective administrators, directors, agents, coaches and other employees or volunteers of
the organization, event officials, medical personnel, other participants, their parents, guardians, supervisors and coaches, sponsoring agencies, sponsors,
advertisers, and if applicable, owners, lessors, and lessees of premises used to conduct the event, all of whom are hereinafter referred to as "releasee", from any
and all claims, demands, losses, actions, causes of actions or damages on account of injury, including permanent disability and death and possible exposure to
and illness from infectious diseases (including but not limited to COVID-19, and damage to property (Collectively, “Liabilities”), caused or alleged to be caused
in whole or in part by the acts or omissions of the release, even if arising from their negligence, OR OTHERWISE to the fullest extent permitted by law.
6. I understand and agree that I may be drug tested at any time, that I am subject to and will abide by the USADA Protocol for Olympic and Paralympic
Movement Testing, its Annexes, and the USOPC National Anti-Doping Policies, and that any dispute related to the foregoing will be resolved exclusively in
arbitration pursuant to the USADA Protocol. Before taking any medications, check the prohibited status at GlobalDRO.com. Also, be sure to download the
Supplement 411 app or visit Supplement411.org to learn how to recognize and reduce the risks related to supplement use. If you have any anti-doping
questions, please don't hesitate to call Athlete Express at (866) 601-2632.
7. I agree to be filmed and photographed under conditions approved and authorized by USA Judo, to include the use of my name, biographical information,
public appearances, interviews, photographs, portrait and motion pictures and television recordings of my judo performance/participation and grant to USA
Judo and Organizers the right to record and make use of the same, and to authorize others to do so in promoting the competition and the success of the judo
team on which I compete, to promote the image of USA Judo, its sponsors and advertisers, and the sport of amateur judo, and to fund the activities of the USA
Judo.
I HAVE READ THE ABOVE WARNING, WAIVER AND RELEASE, UNDERSTAND THAT I GIVE UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND KNOWING THIS,
SIGN IT VOLUNTARILY. I AGREE TO PARTICIPATE KNOWING THE RISK AND CONDITIONS INVOLVED AND DO SO ENTIRELY OF MY OWN FREE WILL. I
AFFIRM THAT I AM AT LEAST 18 YEARS OF AGE, OR, IF I AM UNDER 18 YEARS OF AGE, I HAVE OBTAINED THE REQUIRED CONSENT OF MY
PARENT/GUARDIAN AS EVIDENCED BY THEIR SIGNATURE BELOW.
SAMANTHA AMBULUNDI 11/06/2022

Participant's Printed Name Participant's Signature Date

FOR PARENTS/GUARDIANS OF PARTICIPANTS OF MINORITY AGE (UNDER AGE 18 AT TIME OF REGISTRATION)

This is to certify that I, as parent/guardian with legal responsibility for this participant, do consent and agree to his/her release, as provided above, of all the
Releasees, and, for myself, my heirs, assigns, and next of kin, I release and agree to indemnify and hold harmless the Releasees from any and all liabilities
incident to my minor child's involvement or participation in these programs as provided above, even if arising from their negligence, to the fullest extent
permitted by law. I have instructed the minor participant as to
the above warnings and conditions and their ramifications.
ANA SINCHI 11/06/2022

Parent/Guardian's Printed Name Parent/Guardian's Signature Date

2022_US_Open_Juniors, Seniors, Veterans; Version #2, May 15, 2022 Page 4

 16 Post Tournament Party
As always, there will be a great party following the tournament!

Come Celebrate with us our 33rd year of The Junior US Open

This party will be free of charge to all Athletes, Coaches, Referees, and Tournament Officials.

Parents and family of the athletes are also invited, free admission to those staying at the Official
tournament hotel if space is still available.
To help us in planning and to ensure your admission to the party, please enclose this form with
your athlete’s application.

Athlete’s Name: Judo Club:

TEAM PRADO JUDO
SAMANTHA AMBULUNDI
Check one or more
Number planning to attend: 2 ❑ Parents

❑ Family Members

❑ Friends

2022_US_Open_Juniors, Seniors, Veterans; Version #2, May 15, 2022 Page 5

 21
HOTEL REGISTRATION FORM
The Greater Fort Lauderdale Convention and Visitors Bureau is interested in tracking the hotel use in the area
by the participants in the US Open. Please indicate where you intend to stay during the tournament.
❑ I Live in the local area and will not be staying at a hotel
Tournament Hotel: MARRIOTT HARBOR BEACH
Name of hotel: MARRIOT HARBOR BEACH
❑ Name room reserved under: SAMANTHA AMBULUNDI

❑ Confirmation Number: I39VQGJS

❑ Name of person(s) staying in room:

___________________________________________________________________________________

❑ Hotel other than tournament hotel list (Hotel Name)

❑ Name room reserved under: __________________________________________

Number of rooms reserved:9 Number of nights:7

2022_US_Open_Juniors, Seniors, Veterans; Version #2, May 15, 2022 Page 6