Pan American Taekwondo Union

Union Panamericana De Taekwondo

An Official Pan Am Continental Union of the World Taekwondo Federation
Headquarters: 1109 Edgewood Lane, Fort Lee, New Jersey, USA 07024
Tel. 201-694-1986 / Fax. 201-224-5768 / www.patu.org

POOMSAE REFEREE CERTIFICATION SEMINAR

APPLICATION
Please Check in Appropriate Box

POOMSAE Referee
Certification Course
USD$200.00

POOMSAE Referee
Refresher Course
USD$100.00

Name:________________________
First Name

Age:_________

POOMSAE
Seminar Only
USD$100.00

_____________________

Country:__________________

Last/Family Name

D.O.B.:_______/__________/_________
Date

TKD Rank:__________ Belt

Month

Male:__________

Female:_________

Year

Kukkiwon Dan:_____ Dan

E-mail:___________________________

Current Poomsae Referee Certification: PATU:___________________

WTF:____________________

Address:________________________________________________________________________
City:_______________________

State:_________________

Country:____________________

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LIABILITY WAIVER
I,! the! undersigned,! do! hereby! declare! to! assume! full! responsibility! of! myself! from! all! injuries,! and/or! deaths! and/or!
property!damages!during!PATU!Poomsae!Referee!Certification!Course!and!IR!Refresher!Course,!"#$!further!release,!
waive,!discharge,!and!covenant!not!to!sue!the!Pan!American!Taekwondo!Union,!World!Taekwondo!Federation,!Costa!
Rica!Taekwondo!Federation,!San!Jose!Municipality, San!Jose!National!Gymnasium, the!directors,!the!promoters,!the!
instructors,! other! participants,! volunteers,! operators,! officials,! sponsors,! advertisers,! owners! and! lessee! of! premises!
used! to! conduct! the! course! or! seminar! and! each! of! them,! their! officers! and! employees,! all! for! the! purposes! herein!
referred! to! as!"releases"! from! all! liability! to! myself,! for! any!and! all!damage,! and! any! claim! or!demands!therefore! on!
account!of!injury!to!the!person!or!property!or!resulting!in!death!of!myself,!whether!caused!by!the!negligence!of!the!
releases!or!otherwise!while!I!am!in!or!upon!the!resurrected!area,!participating,!observing,!or!working!for,!or!for!any!
purpose!of!participating!in!the!above!mentioned!course!or!seminar.!
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Signature!of!Participant! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! Date