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your registration form here.
White Dragon Warrior Society
International Conference 2016
Friday, September 30 - Sunday October 2, 2016
Milwaukee, WI
Registration Form
This form has been designed with fields that allow you to fill it out on your computer. Once
complete you can press the "Print Form" button at the bottom to print the completed form to
send in. Please remember, you need to fill out one form per participant.
PLEASE COMPLETE IN ITS ENTIRETY.
Personal Information
LAST Name
FIRST Name
City
State
Email
Phone
Instructor' Name:
Gender
Age
Male
✔
Rank
Female
Weight
TOURNAMENT
“Lower Ranks” Tournament WITH SEMINARS
Forms External
Forms Tai Chi ✔
Sparring ✔
1 Event = $60
2 Events = $65
3 Events = $70
Sparring
1 Event = $85
2 Events = $90
3 Events = $95
“Lower Ranks” Tournament ONLY
Forms External
Forms Tai Chi
Forms Tai Chi
1 Event = $60
2 Events = $65
3 Events = $70
4 Events = $75
5 Events = $80
Forms Tai Chi
1 Event = $85
2 Events = $90
3 Events = $95
4 Events = $100
5 Events = $105
“Black Belts” Tournament WITH SEMINARS
Forms Kung Fu
Forms Weapons
Forms Kenpo
Sparring
“Black Belts” Tournament ONLY
Forms Kung Fu
Forms Weapons
Forms Kenpo
Sparring
Tournament Subtotal
Spectator (1 Day Pass)
Spectator (2 Day Pass)
x $10
x $20
Height
$ 0
Children Under 6 Free Spectator $
0
Subtotal
SEMINARS
All Students attending the conference are encouraged to participate in the Seminars.
They are always valuable learning experiences full of information not often taught elsewhere.
Unlimited - $200
Children’s Track - $75
Seminar Subtotal
$ 0
Banquet Subtotal
$ 0
(14 Years and Under)
BANQUET
x $40 = $ 0
Banquet and Lunch
- Adults
x $30 = $ 0
Banquet and Lunch
- Children
(12 and under)
Testing: YES:
NO:
TESTING AND REVIEWS
✔
Discipline: Tai Chi / Internal
Rank: Choose
Testing Subtotal
Review: YES:
NO:
✔
Discipline: Tai Chi / Internal
Rank: Choose
Review Subtotal
REVIEW
YELLOW ORANGE PURPLE
$50
$60
$60
1 Star
$50
TEST
San Shou Fighter
2 Star
$75
3 Star
$100
YELLOW ORANGE PURPLE
$60
$70
$80
1 Star
$75
San Shou Fighter
2 Star
$100
Membership
YES:
Current?:
Student ($25)
3 Star
$150
NO:
BLUE
$70
GREEN BROWN
$70
$80
4 Star
$150
BLUE
$80
1 Star
$75
3 Star
$150
GREEN BROWN
$80
$90
4 Star
$250
1 Star
$100
4 Star
$250
GRAY BLACK I BLACK II BLACK IIIBLACK IV
$100
$250
$300
$350
$400
San Shou Coach
2 Star
$150
3 Star
$200
4 Star
$300
WDWS Membership
Expiration Date:
If membership expired by 9/1/2016 you must renew at Conference
SiFu / SiHing ($50)
School ($100)
$ 0
GRAY BLACK I BLACK II BLACK IIIBLACK IV
$90
$100
$150
$200
$250
San Shou Coach
2 Star
$100
$ 0
Membership Subtotal
$ 0
2016 CONFERENCE T-SHIRTS PRE-ORDER
Children’s
Small
Medium
Large
XL
x $30 = 0
x $30 = 0
XXL
XXXL
x $30 = 0
x $30 = 0
x $30 = 0
x $35 = 0
x $35 = 0
T-Shirt Pre-Order Subtotal $
0
PAI LUM TAO BOOKS PRE-ORDER
x $25.00 = 0
This Is...Bok Leen Pai Kenpo
x $25.00 = 0
This Is...Pai Lum Tao’s
Internal Hand
This Is...Chin Kon Pai Meditation
x $25.00 = 0
This Is...Pai Te Lung Kung Fu
x $25.00 = 0
Set of all four books
(save $5.00 a book!)
x $80.00 = 0
Book Pre-Order Subtotal
$ 0
TRANSPORTATION
Adults (per person)
0
Children under 12 (must be with
0
immediate family)
x $10 =
0
x $5
0
=
Transportation Subtotal
$ 0
Please be sure to complete and turn in your separate transportation form.
(Late transportation requests made after August 30th, 2016 will be charged $20/person)
The purpose of setting this date is to allow time for scheduling pickups, so please remember to submit Transportation Requests early!
Pickup times are based on requests received and are designed to minimize wait time while maximizing the number of people using the service.
Please provide your travel itinerary even if you know that a pickup is being made that will serve you.
A Non Refundable Deposit of $75.00
must be postmarked by August 30, 2016
$35.00 Late Fee will be strictly enforced
(Post Marked After August 30, 2016)
Late Fee Subtotal
Grand Total $ 0
- Deposit $ 0
- Fundraiser Amount $ 0
$0
Balance Due $ 0
Please make all checks payable to: Pai Lum Tao
MasterCard & Visa Accepted
To Pay By PayPal or Credit Card Please Call (262) 662-3800.
A handling charge of 3% will be added.
DO NOT EMAIL CREDIT CARD INFORMATION
Please mail this registration form along with your non refundable deposit made out to
Pai Lum Tao, W362S10150 Lewin Ln., Eagle, WI 53119
Postmarked by August 30, 2016
THIS FORM IS NOT COMPLETE WITHOUT
SIGNING THE WAIVER ON PAGE 5
New Horizons
Grandmaster Glenn C. Wilson
Invite you to celebrate Pai Lum Tao’s New Horizons
Dress to Impress in your Best!
~Learning from the past
Celebrating the moment
Forging the future~
The White Dragon Warrior Society is pleased to announce that we will be providing special room rates
at the Hyatt Place Milwaukee West. All events will be held at Henry L. Palmer Masonic Lodge, and we
request that all conference attendees stay at the official Conference hotel. Call 414-462-3500 and use
the code “Pai Lum Tao” to secure your room at the group rate.
Hyatt Place Milwaukee West
11777 W. Silver Spring Drive
Milwaukee, WI 53225
Waiver
This Registration form is not complete, unless signed.
I, the undersigned, knowingly, without duress, do voluntarily submit my entry into the 2016 White
Dragon Warrior Society International Conference Tournament. I assume all risk of personal, physical
and mental disabilities, injuries, death or losses, which may result from participating in the tournament. Acting for heirs, my personal representatives, assignees, and myself, I do hereby release
Grandmaster Glenn C. Wilson, Glenn Wilson’s Martial Arts Academy and The White Dragon Warrior
Society, their officials, agents, representatives, employees, and any other related members from
liability due to any injuries or death incurred and any resulting legal claims, actions suits, or controversies. I assume full responsibility for all of my actions, activities or omissions during and in connection
with the Tournament. Additionally, I am fully aware of my personal medical condition and hereby
certify that I am mentally and physically fit to compete.
Parent’s or Guardian’s signature required if contestant is less than 18 years of age.
Signature of Contestant_____________________________________________ Date ____________
Signature of Parent/Guardian ________________________________________ Date ____________
Please mail this registration form along with your non refundable deposit made out to
Pai Lum Tao, W362S10150 Lewin Ln., Eagle, WI 53119
Postmarked by August 30, 2016
White Dragon Warrior Society
International Conference 2016
Friday, September 30 - Sunday October 2, 2016
Milwaukee, WI
Transportation Request Form
Fellow Dragons:
This form has been designed with fields that allow you to fill it out on your computer. Please
fill out one form per party arriving on the same flight. PLEASE COMPLETE THIS FORM IN
ITS ENTIRETY.
We are pleased to announce that Wisconsin Pai Lum Tao will provide round-trip transportation between the
Milwaukee Airport and the official Conference hotel - the Hyatt Place Milwaukee West. Transportation services
will begin on Friday, September 30th and conclude on Monday, October 3rd. If you are traveling on dates
outside of this range we suggest contacting the Hyatt Place Milwaukee West hotel for alternate arrangements.
In order to assist us with coordinating our transportation please fill out this form completely, and email it back
to SiGung Scott Muelling at [email protected]
If we receive a completed form by August 30th, 2016, every effort will be made to provide transportation. Due
to situations beyond our control, failure on your part to return this form on time or travel dates outside of our
scheduled range you MUST arrange your own transportation. You will be notified in advance if we are unable
to supply you with transportation. All air travel must be booked through Milwaukee International Airport.
Please complete ALL of the following fields. For flight numbers, please give us the number of the flight at the
MILWAUKEE airport. Check your flight itineraries - if you have a connection the flight number you arrive on
may not be the same flight you depart on from your home city. Please complete seperate forms for seperate
itineraries. If you are using our transportation services, please be sure to include the costs for this on
page 3 of your registration form.
Your Name:
Home Phone #:
Cell Phone #:
Email Address:
Arrival Date (in Milwaukee)
Airline arriving
Flight #:
in Milwaukee on:
Departure Date (from Milwaukee)
Airline leaving
Flight #:
Milwaukee on:
City arriving flight begins in
(might not be your home city
in the case of a connection)
City departure flight leaves for
(might not be your home city
in the case of a connection)
ARRIVAL TIME IN MILWAUKEE
DEPARTURE TIME
FROM MILWAUKEE
NUMBER OF PASSENGERS
IN YOUR PARTY
ADDITIONAL INSTRUCTIONS:
1. Upon Arrival: Go to baggage claim, get your bags, and go outside of baggage claim at pick up area. It may be a 30-60
minute wait, please be patient.
2. Upon Departure: You and your party MUST be ready to travel and waiting in the hotel lobby 2 hours before your flight.
3. Any flight delays, cancellations, questions, etc. please call (262) 662-3800.