USA Judo Junior Membership and Promotion Form – January
2004
Note:
This form is to be used by all persons 16 years of age and
younger who wish to become
USA Judo members, or to be promoted to any USA
Judo Junior Judo Rank. The same
form
may be used to validate and register a new Junior member.
Please complete all blanks and
print clearly to prevent errors.
SECTION
1: TIME IN GRADE REQUIREMENTS
FOR PROMOTION TO ALL USA Judo JUNIOR JUDO RANKS
For
the USA Judo Junior Judo Ranks, the required time in grade is three months,
either as a
white belt beginner, or in the previous rank.
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SECTION 2:
MEMBERSHIP FEE
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The USA Judo annual
registration fee for all Juniors 16 years of age and younger is $50.00. This
includes $25,000 in personal liability insurance.
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SECTION 3:
PROMOTION FEES
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The
USA Judo promotion fee for all USA Judo Junior Judo ranks is $10.00.
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$2.00 will be remitted
to the
player's club |
$3.00 will be remitted
to the state
"Class B Organization"
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$5.00
will be remitted to USA Judo's national office:
- $1.00 will be remitted to
administration fees
- $4.00 will be remitted to Junior
Judo Rank System Development Fund
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SECTION
4: PERSONAL INFORMATION-MUST
BE COMPLETED FOR BOTH MEMBERSHIP AND
PROMOTIONS
Name:
____________________________________________________________________Date:_____________
(First, Middle, Last)
Address:_____________________________________________________________________________________
(City)
(State) (Zip Code)
Birth Date:_____________ Age:________ Present Junior Judo Rank:__________
(If
renewal member)
Home
Phone:______________________ Fax Number:_____________________
E-Mail:_____________________
Club
Name: __________________________ Club Coach:_____________________________________________
Coach’s
Address________________________________________________ E-Mail
________________________
(City) (State) (Zip Code)
SECTION
5: MEMBERSHIP FEE-FOR
MEMBERSHIP APPLICATION ONLY
USA Judo Membership Fee Enclosed $________________
(See
Section 9 for credit card information)
SECTION
6: JUNIOR PROMOTION
INFORMATION TO BE COMPLETED FOR PROMOTIONAL
PURPOSES ONLY
This
is a promotion to Junior ______ Degree.
This Junior has _____ months as a white belt, or _____ months
in grade as a
Junior _____ Degree.
I
certify that this Junior has attended _____ practices as a white belt or
since their last promotion. I
certify that this Junior has competed in _____ competitions as a white belt
or since
their last promotion, with _____ wins and _____ losses.
I
certify that this Junior has demonstrated proficiency
with all
techniques required for this rank in the Junior Ranks section of
the USA Judo Junior Judo
Rank System.
SECTION
7: JUNIOR PROMOTION FEES
USA
Judo Promotion Fee Enclosed $___________
(See
Section 9 for credit card information)
SECTION
8: CERTIFICATION OF COACH OR
EXAMINER
I
certify that all the information I have entered on this form is true and
correct to the best of my knowledge and
belief.
Signature
of Club Coach: ____________________________________________________
Date:______________
Printed
Name:________________________________________________________________________________
Address:____________________________________________________________________________________
(City) (State) (Zip Code)
Club
Name:_________________________________________________________________________________
Date
Recommended:________________________________
SECTION
9: CREDIT CARD AND PAYMENT
INFORMATION
Type
of Credit Card: Visa _____
Master Card _____
Card
Number:__ __ __ __-__ __ __ __-__ __ __ __-__ __ __ __
Expiration
Date:_____/_____
Name
as it
appears on card_____________________________________
(Please print)
Signature:____________________________________________-
Total
amount charged: $_______________
Check
enclosed: #________________ $____________________
Print as many forms as needed.
USJI does not bulk ship forms.
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