First Name

Last Name

Address

Address 2

City

State

Zip

Phone

Cell Phone

Email

Birthdate

(Ex. MM/DD/YYYY)

Weight

Gender

Male Female

Team

Belt Rank

--Select Belt Rank-- White Blue Purple Brown Black

Experience Level

--Select Experience Level-- Novice (0 - 6 months) Beginner (6 months - 1 1/2 years) Intermediate (1 1/2 - 3 years) Advanced (3 - 6 years) Expert (6 years and more)

Division

Men Masters Women Kids Teens

Name on Card

Credit Card Number

Exp Date

(Ex. MM/YYYY)

CVV

I understand that by entering this competition I may entail some risk of accident or injury and that this risk may be in the form of an accident that may be serious or even mortal. I further understand that I have had explained to me that along with the possibility of personal injury that injury to property is also possible, such as, but not limited to, possible loss of wages and the ability to earn such. With full knowledge of the aforementioned dangers both to my person and to my property (current and further) And after having these dangers fully explained to hold free of discharge from any liability, Fight Hub LLC and/or EGO there agents, employees, or representatives, of and from all claims, demands, rights and causes of action of any danger whatsoever which I may have or which may hereafter accrue to me, arising from and by any reason of any and all bodily or personal injury, damage to property or other loss, and any consequences thereof, which known or unknown, seen or unforeseen, resulting from my participation in this competition, the persons and entities mentioned above.

I Agree