Capital City Open
Spring Karate Championships
Sunday, April 19, 2015
Name________________________ Karate School_______________________________
Age_____ Male____ Female____ Belt Level____________
Email_____________________________________
Under Black Belt Divisions *
___ Forms
____Sparring**
____Weapons
Black Belt Divisions*
Weapons___ Sparring___
___Traditional Forms ___Freestyle Forms
* No music is allowed in any division other than Grand Champion.
**Full gear is required for ALL minor competitors, including chest protectors.
Pre Registered price $35…………………..________
Same Day Registration $40………….________
Pre Reg. Additional Events ___x$12………...________
Same Day Additional Events ___x$15………________
Advanced Spectators____ x $3……………...________
Day of Spectators ____x$5 ……………….________
Pre Registered Family Rate $110………….________
Same Day Family Rate $125………...________
Total Amount Paid………………….________
Drop completed form and check made out to Karate America at any Plumer Karate
America School OR Mail to: 125 Lodi St. Lodi, Wisconsin 53555
** Pre-registered forms MUST be received no later than Thursday, April 16th!**
I understand that there are risks associated with any physical activity and contact
sports and I take full responsibility for myself and (or) my child’s well being during this
activity. Plumer Karate America, it’s officers and employees are not liable for any injury
that may occur during or after this tournament.
Tournament Location: Lodi Middle School
900 Sauk Street
Lodi, Wisconsin 53555
Start Time: Registr ation opens at 8:00am. Weapons competition star ts at 9:00am,
followed by forms and sparring.
Parents Signature_____________________________________ date______________
Student’s signature____________________________________ date______________
*Participants under 18 MUST have Parent’s signature to compete.
For more information, please call Mr. Jon Plumer at 608-592-4800
All minors under the age of 18 MUST have a parent or guardian’s signature to compete.