| Weight_________________________ Branch_____________________ Full Name: ________________________________________________Gender M/F Current Age: _____ (D.O.B.):___/___/___ Height in Feet & Inches: ___’___” Fight Weight in kg_______ P.O. Box or Street Address: __________________________________________________ City: ____________________________State:_____________________Zip Code: ____________ Gym Name: ____________________________________Contact phone number:s mobile_________________________home phone___________________________ Trainers Name ___________________________________________ E-Mail (If One):______________________@____________________________ Fight record: Kickboxing: ___ Wins___ Loses___ Draws___ KO’s/TKO’s *Please fill this out for the doctor* Have you ever been knocked out? Y N If so, how many times? ___________________________ What was the date of your last knock out? ____________Do you have any debilitating injuries? Y N Have you ever broken any bones? Y N If so, which bones? __________________________ Are you currently on any medication? Y N If so, what are they? _____________________ Have you ever, or are you currently using any type of illegal steroids? Y N Have you ever been addicted to any illegal substances? Y N If so, what were they? _____________ What was the date of you last fight? _____________________ Doctor’s Notes: __________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Release Form I, the undersigned, do hereby voluntarily submit my application for attendance and participation in The WASKO 2007 WORLD AMATEUR KICKBOXING CUP held 17-18 NOVEMBER at the BUYUK ANADOLU HOTEL hereby assume full responsibility for any and all damages, injuries, or losses that I may sustain or incur, in anyway, while participating. I hereby waive all claims against the promoters and participants of the 2007 WORLD AMATEUR KICKBOXING CUP, Buyuk Anadolu Hotel, the WASKO, Selahattin BIYIKLI, their agents, employees, officers, and directors, individually or otherwise, for any injuries that I may sustain. I give my consent to any pictures taken of me in connection with the exhibition which may be used for publicity, promotion, or TV showing, and I waive compensation in regard thereto. If under 18, this release and consent form is also to be signed by parent or guardian. __________________ _________________________ ________________________ DATE OF EVENT SIGNATURE OF FIGHTER WASKO REP. | 
