East Coast Karate Championship Tournament

Pre-Registration $50.00 for four events.  If registering at the door add $15.00  for four events.  
Please Mail Form to: Charlie Gilantzis
P.O. Box 58 Kenly, N.C. 27542

Name______________________________________Age____Rank_______Male___Female___

Address_____________________________City___________________State_____Zip_________

Instructor's Name________________School______________Phone_______Email____________
No checks accepted on day of Tournament & No Refunds.

I,  release East Coast Karate Championship & Promoters and anyone else
connected with the directing, promoting, judging in the East Coast Karate Championship
Tournament , from all responsibilities due to accidents, loss of valuables, or even the loss of life due
to injury or accident that may occur during the entire event as a direct or indirect result of the event.

The following is a request of release to use the individual listed above's photo and name on our website. Such
information is to be used solely for the purpose of recognizing winners and participants in the
Eastcoastkaratechampionship Tournament. Their addresses or phone numbers will not be listed, neither will their age.

Please initial your preference.

____ Yes, I give  East Coast Karate Championship permission to use any information listed in the release
on their website.

_____ Please do not use any of my information on your website.



Release Signature__________________________________________



If under 18, this release and consent form must be signed by a PARENT or LEGAL GUARDIAN.


List Division# For all Divisions You Are Competing In. See Divisions List! Kata-Sparring-Weapons and
Self Defense.
1.______2.______3.______4.______

Total amount enclosed:________________


Contact us
Tournament
Divisions