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Phone Number Type Mobile Work Home Date of Birth * Age * Country of Citizenship * Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Colombia Comoros Congo Costa Rica Côte d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland France French Guiana French Polynesia Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Zealand Nicaragua Niger Nigeria Norway Northern Mariana Islands Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Sudan Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Yemen Zambia Zimbabwe Foreign Address Fee Applies Registration Type * Choose a Registration Type Adult 1 Year $40 Adult 5 Years $180 Youth 1 Year $20 Youth 5 Years $90 Youth (age 16 or younger) Adult (age 17+) Instructor Name * Club Name Club Number Which Art(s) Do You Have Rank In? * Judo Jujitsu Both Date Judo Rank Obtained Choose Appropriate Judo Rank * JR00 (Junior/White) JR01 (Junior/Yellow) JR02 (Junior/Yellow Stripe) JR03 (Junior/Orange) JR04 (Junior/Orange Stripe) JR05 (Junior/Green) JR06 (Junior/Green Stripe) JR07 (Junior/Blue) JR08 (Junior/Blue Stripe) JR09 (Junior/Purple) JR10 (Junior/Purple Stripe) JR11 (Junior/Brown) JR12 (Junior/Brown Stripe) Shichikyu (Adult/White) Rokyu (Adult/Yellow) Gokyu (Adult/Orange) Yonkyu (Adult/Green) Sankyu (Adult/Brown 3) Nikyu (Adult/Brown 2) Ikkyu (Adult/Brown 1) ----------------------------- Shodan Nidan Sandan Yodan Godan Rokudan Shichidan Hachidan Kudan Judan Choose Appropriate Jujitsu Rank * Jukyu (junior rank) Kukyu (junior rank) Hacjikyu (junior rank) Shichikyu (junior rank) Rokyu (white) Gokyu (blue) Yonkyu (green) Sankyu (brown 3) Nikyu (brown 2) Ikkyu (brown 1) ----------------------------- Shodan Nidan Sandan Yodan Godan Rokudan Shichidan Hachidan Kudan Judan Date Jujutsu Rank Obtained In consideration of being allowed to participate in any way in the American Traditional Jujutsu Association martial arts program(s), and related events and activities, the undersigned: Agrees to complete and comply with the SafeSport program in order to maintain their ATJA membership. Agree that the parent(s) or legal guardian(s) will instruct the minor participant that prior to participating, he or she should inspect the facilities and equipment to be used, and if the participant believes anything is unsafe, he or she will immediately advise his or her coach or supervisor of such condition(s) and refuse to participate. Acknowledge and fully understand that each participant will be engaging in activities that involve risk of serious injury,including permanent disability and death, and severe social and economic losses which might result not only from their own actions, inaction or negligence but the actions, inaction or negligence of others, the rules of play, or the condition of the premises or of any equipment used. Further, that there may be other risks not known to us or not reasonably foreseeable at this time. Assume all the foregoing risks and accept personal responsibility for the damages following such injury, permanent disability or death. Release, waive, discharge and covenant not to sue the American Traditional Jujutsu Association, its officers, its affiliatedclubs, their respective administrators, directors, agents, coaches, and other employees of the organization, other participants, sponsoring agencies, sponsors, advertisers, and, if applicable, owners and lessees of premises used to conduct the event, all of which are hereinafter referred to as 'releasees' from any and all liability to each of the undersigned, his or her heirs and next of kin for any and all claims, demands, losses or damages on account of injury including death or damage to property, caused or alleged to be caused in whole or in part by the negligence of the releasee or otherwise. This is a Waiver and Release of Liability: Clear REGISTRANT OR PARENT/GUARDIAN SIGNATURE HERE Date * Tax Deductible Donation Total * Portrait picture image for your registration card Drop a file here or click to upload Choose File Maximum upload size: 5MB file size limit is 5MB Any additional document you wish to send in for your registration Drop a file here or click to upload Choose File Maximum upload size: 5MB file size limit is 5 mb & no more than 3 files reCAPTCHA If you are human, leave this field blank.