Point of Contact's Name and Email Address:
 

Annual number of tournaments sponsored:
(if more than six, please use additional applications)

Anticipated Date(s) Location of participants to include:
              Name,                 Date,                  Street,                      City,              State,           Zip:
1.      
2.      
3.      
4.      
5.      
6.      

Does the school require a signed Hold Harmless agreement from participants?  Yes   No
If Yes, either email agreement to brownsins@aol.com or mail a copy to the address above.

Events contemplated at all Tournaments:
Free Sparring
Forms (Kata, etc.)
Weapons forms
Breaking
Other (describe): 

This policy does not provide coverage for any claim, suit or cause of action arising out of any injury
to the head of a contestant actively engaged in free sparring, unless at the moment such injury takes
place, the injured contestant and his/her opponent are wearing approved protective headgear, padded
kickingboots, and dental protective devices (mouthpiece).

I HEREBY DECLARE TO THE BEST OF MY KNOWLEDGE AND BELIEF THAT ALL OF
THE FOREGOING STATEMENTS ARE COMPLETE AND TRUE AND THAT THESE
ARE OFFERED AS AN INDUCEMENT TO THE COMPANY TO ISSUE THE POLICY FOR
STATEMENTS WHICH I AM APPLYING. IT IS UNDERSTOOD AND AGREED THAT THE
COMPLETION OF THE QUESTIONNAIRE DOES NOT BIND THE INSURANCE COMPANY.

Applicant's Name:  Date:

Producer's Name:   Date: