Pre-Registration Form:
We have to have original signature on file - Please fill it out, print &  mail it in to:
Larry or Sandy Dillingham - PO Box 3238 - Salisbury NC 28145

$40 for 1 event, $10 for each additional event. Return by August 18, 2008. Certified Check & Money Orders will only be accepted made out to Larry or Sandra Dillingham PO Box 3238, Salisbury NC 28145.  No personal checks will be accepted. Bring birth certificate for age verification.


Name: DOB  Age: 
M F  Phone ()-

Address  City 
St Zip 

Instructor:  Studio Address 
City  St  Zip Studio Phone (-

Please list division # for all divisions you are competing in. See division list. Breaking, Self-Defense, Musical, BB Musical Weapons 17-, Traditional Weapons, Traditional Forms, Open Weapons, Open Forms, Handicap able Form/Weapons, Sparring.

1. 2. 3. 4. 5. 

 6. 7. 8. 9. 10. 

1 event $40.00  Coach’s Pass: $15.00   Spectator Fee $7.00 

After August 18, 2007:
1 event $45 Plus x $15 per additional event
Spectator Fee: $7.00= Total $

RELEASE/WAIVER
I, the undersign, do hereby voluntarily submit my application for attendance/participation in Larry & Sandy Dillingham’s 13th Annual Foothills Karate Classic and do hereby assume full responsibility for all damages, injuries and losses that I may sustain or incur in any way while attending and participating in this event. I also waive all claims against the Promoters, North Rowan High School, Rowan-Salisbury Schools, or anyone directly or indirectly associated with this tournament for any claim or injury that I may sustain.

Signature of Competitor (Parent if competitor is under 18) ________________________________      Date: ____________________