The 28th Liberty Bell Judo Classic Application Form

THE TWENTY-EIGHTH ANNUAL
LIBERTY BELL JUDO CLASSIC

March 28, 2015
A USA Judo Sanctioned Event
A Level D Senior Event
Schedule:

Location:
Tournament Directors:
Eligibility:
Online Registration:
Awards:
Elite D^E
& Elite Open Female Prize
Awards
For Olympic Weight Classes Only
NEW
5 mat
areas
2015
FRIDAY MARCH 27th

REGISTRATION & WEIGH IN
6-8pm
Juniors & Youth
7-9pm
Seniors & Masters
Special note:
SATURDAY MARCH 28th

COMPETITION
8:00am
Site Opens
8:30am
Coaches Meeting
9:00am
Competition Seniors/Masters
Absolutely NO REGISTRATION at the field house
10:00-11:00am Junior/youth weigh in (No
the morning of competition. Special junior/youth
Registration, See Next Page)
weigh in Saturday morning, see next page for
12:30 pm Opening Ceremony
requirements *
1:00 pm Junior Competition (start time

based on completion of Seniors)
REGISTRATION & WEIGH IN
COMPETITION
The Radisson Hotel
Asplundh Field House Academy of New Church
2400 Old Lincoln Hwy, Bensalem, PA 19053
2775 Buck Road, Bryn Athyn PA 19009
(215) 638-8300
(267) 502-2573

Tony Kenis
215-469-0342 215-695-5510 Libertybelljudo@gmail.com
Adam Moyerman
215- 815 -2555 Libertybelljudo@gmail.com
Lou Moyerman (Registration Chairman) - 215- 313- 2098
No Email Entries Accepted

Any judoka, age 5 to adult, who has a CURRENT USA Judo, USJA or USJF Card or National Passport
Card for foreign athletes. Judo players must present card at registration. A photocopy of your
card/judo passport must be sent with your application.

www.libertybell.com
Available until 3/25/15

1st - 2nd 3rd place Liberty Bell Judo Classic Medals for each division.
Special Awards

Per Weight Class
1st Place
2nd Place
3rd Place
2-5 Competitors
$100

6-12 Competitors
$250

13-19 Competitors
$350
$150

20+ Competitors
$400
$200
$50

Rules:

1.
2.
3.
4.
5.
6.
7.
8.
IJF Rules will govern, except

a. No arm locks under 16 or in any novice divisions
b. Mat-side coaching will be allowed in all divisions
c. Players will be allowed to change gis to conform to the rules, without being penalized.
All female contestants are required to wear a plain white t-shirt or leotard to compete.
Blue & white judo gis are required for Male Nikkyu & Above and Open Female Divisions
All contestants, including juniors, must bring at least one white gi.
A player called to white side must wear a white gi, or forfeit- no exceptions
Modified Double Elimination for all pools (3 & 4 man pools will fight Round Robin)
No chokes for 12 and under. Shido penalty will be given to athletes 12 and under for leg
grab
Current IJF medical rules will apply to all divisions (no examination except for blood or grave
injury)
Match Times: Juniors, masters, female novice, and male sankyu and below 3 minutes
All youth and elite female open 4 minutes
Male elite nikyu and above 5 minutes
SPECIAL Junior and Youth
Weigh-Ins:

New this year!

Saturday morning 10:00-11:00 AM at Field House
ONLY FOR ATHLETES WHO DECLARE THIER WEIGHT CLASS(ES) ON APPLICATION
Requirements:
1. This is a WEIGH-IN ONLY, NO LATE REGISTRATION will be taken Saturday
2. Athletes must be PREREGISTERED AND PAID.
3. Athletes MUST DECLARE THEIR WEIGHT CLASS(ES) ON APPLICATION
4. Athletes MUST MAKE DECLARED WEIGHT CLASS OR BE DISQUALIFIED WITH NO
REFUND.
NOTE: Juniors 12 and Under may fight 2 Weight Classes in their Age Category
Juniors and Youth 13 and Over may fight 2 Weight Classes in their Age Category OR their
weight class in their age category and the next age category
IF FIGHTING MULTIPLE DIVISIONS YOU MUST FILL OUT 2 ENTRY FORMS

Junior Boys
Ages 5-6
<20
23
28
28+

7-9
<23
26
30
34
38
44
44+

10-12 <30
33
36
40
44
50
57
64
64+

13-16 <41
45
50
55
60
66
73
81
81+
Junior Girls
Ages 5-6
<20
23
28
28+

7-9
<23
26
30
34
38
44
44+

10-12 <30
34
39
43
48
54
54+

13-16 <41
44
48
52
57
63
70
70+

Youth Male
Ages 17-19 <60
66
73
81
90
90+
Youth Female
Ages 17-19 <52
57
63
70
70+

Senior Women
All Ranks

<44
48
52
57
63
70
78
78+
Novice white & green

<57
66
>66

Senior Men
Sankyu & below

<60
66
73
81
90
100
100+
Nikkyu & above
<55
<60
66
73
81
90
100
100+

Masters (30 and over All Ranks)
Men

<70

81

94

94+
Women

Lwt

Hwt

All weights in kilograms
2.2 pounds=1 kilogram
Seniors & Masters

Divisions

All weights in kilograms
2.2 pounds=1 kilogram
Junior & Youth

Tournament director reserves the right to make any changes deemed necessary to ensure safety and fairness for all competitors.
Hotel Information:
Main Hotel:
The Radisson Hotel
2400 Old Lincoln Hwy, Bensalem, PA 19053
(215) 638-8300
Rate $115 if reserved by February 26th
Overflow Hotel:
Four Points Sheraton Hotel
9461 Roosevelt Blvd, Phila, PA 19114
(215) 671-9600
(must mention Liberty Bell Judo)

**NOTE** No transportation will be provided from the hotel to the venue

ENTRY FORM
JUNIOR & YOUTH ONLY

TOTAL COST in USD ($)

FIGHTING DIVISION(S)
1 Junior/Youth Division
2 Junior/Youth Divisions (up one weight class)
1 Junior/Youth Division + 1 Senior Elite Division
Pre-Registration
Postmarked
by March 20
Late Registration
Received on or
After March 24
$70.00
$95.00
$115.00
$90.00
$130.00
$150.00
x
x
x
Juniors 12 and Under may fight up one weight category

Juniors and Youth 13 and Over may fight up one weight category OR up one age category in their weight class
ALL ATHLETES COMPETING IN TWO CATEGORIES MUST FILL OUT TWO FORMS!
Late Registration is available the evening prior to competition at the Tournament Hotel Headquarters.
Make all checks payable >:/Adam and Lou Moyerman, 9821 Ferndale St Philadelphia PA 19115.

NO PHONE ENTRIES. NO FAX ENTRIES. NO EMAIL ENTRIES. NO REFUNDS.

>E&E

Address: _______________________________________________________________________________________________________

City: ____________________________________ State ______Zip _____________Tel. # _____________________________________

Judo Club:_________________________________________________________ Rank: ______________________________________

USA JUDO USJA USJF Card # _______________
_____Exp Date_________________Age: ____________Sex: M F

Foreign Athlete Judo Passport # ____________________USA Citizen Yes No Email ______________________
_________

Division - Please check

Gender:
Boys
Girls
Age Group:
5-6
7 9
10 12
13 16
Weight Class: __________ weight in kgs only (2.2 pounds = 1 kg)
17-19

*For our reference are you planning to weigh-in:
Friday Night Saturday Morning

I certify that all of the above information is correct. __________________________________________________________________

Signature: (Contestant 18 years or older or Parent /Guardian)

Please note:

1. It is mandatory that the enclosed liability waiver be signed in order to participate.

2. Anyone failing to fill out the necessary forms can be disqualified from the tournament.
It is mandatory that all non-black belts competing in Nikkyu & Above, Masters, Youth and Sr. Female divisions complete certification
below:

I, ______________________________________________, a Judo Instructor, who has been awarded the Judo rank of Shodan or higher,
under the auspices of United States Judo Inc, United States Judo Association, and/or United States Judo Federation, hereby certify that
the above contestant, although not having been awarded the Judo rank of Shodan or higher, is of sufficient aptitude and skill in Judo to
compete in the Liberty Bell Judo Classic.
h^:/sis

Signature of Judo Instructor ________________________________________________________ Rank __________________________
ENTRY FORM
SENIOR MALE SANKYU BELOW AND FEMALE NOVICE DIVISIONS

Pre-Registration
Postmarked
by March 20
Late Registration
Received on or
After March 24
$70.00
$95.00
$90.00
$130.00
1 Division
2 Divisions


D>:/>D&^WW.


Last Name _____________________________First Name________________________Date of Birth: ________________

Address: ______________________________________________________________________________________________________


Judo Club:__________________________________________________________Rank: ______________________________________


_________

Division:
Senior Novice Women Men Sankyu & Below


I certify that all of the above information is correct. _________________________________________________________________

Signature: (Contestant 18 years or older or Parent/Guardian)

Please note:


ENTRY FORM
SENIOR MALE NIKKYU & ABOVE/FEMALE OPEN DIVISIONS ONLY

1 Division
2 Divisions
Pre-Registration
Postmarked
by March 20
Late Registration
Received on or
After March 24
$90.00
$115.00
$110.00
$150.00


D>:/>D&^WW.


>E&E

Address: ______________________________________________________________________________________________________


Judo Club:__________________________________________________________Rank: ______________________________________


_________

Division:
Senior Female Open Male Nikkyu & Above


I certify that all of the above information is correct. _________________________________________________________________

Signature:

Please note:


below:

h^:/sis
attached. Competitors in the above categories

Signature of Judo Instructor __________________________________________________ Rank ________________________________
ENTRY FORM
MASTERS ONLY

Pre-Registration
Postmarked
by March 20
Late Registration
Received on or
After March 24
$70.00
$95.00
$90.00
$130.00
1 Division
2 Divisions


D>:/>D&^WW.


>E&E

Address: ______________________________________________________________________________________________________


Judo Club:__________________________________________________________Rank: ______________________________________


_________

Division - Please check

Gender:
Male
Female
Age Group:
30-39 40-49
50 & over

I certify that all of the above information is correct. __________________________________________________________________

Signature

Please note:


below:


h^:/sis

Signature of Judo Instructor ____________________________________________________ Rank ______________________________
WARNING!
WAIVER AND RELEASE OF LIABILITY AND AGREEMENT TO PARTICIPATE

In consideration of being permitted to participate in any way, including travel to and from, in any Judo tournament, practice,
clinic, and related events and activities of the United States Judo Federation, Inc., United States Judo, Inc., United States
Judo Association, Inc., Pa Judo Inc., Shufu Judo Yudanshakai, Liberty Bell Judo Inc, Liberty Bell Judo Classic, Academy of
New Church, and Liberty Bell Georgian Judo Academy, I hereby:

1. Acknowledge that I am familiar with the sport of Judo and understand the rules governing the sport of Judo.

2. Agree that, prior to participating, I will inspect the mats, equipment, facilities, competition pools or divisions, and
the elimination or scoring system to be used, and if I believe anything is unsafe or beyond my capability, I will immediately
advise my coach, supervisor, and/or a tournament official of such conditions and refuse to participate.

3. Acknowledge and fully understand that I will be engaging in a contact sport that might result in serious injury,
including permanent disability, Traumatic Brain Injury (TBI),or death, and severe social and economic losses due not only to
my own actions, inactions or negligence, but also to the actions, inactions, or negligence of others, the rules of the sport of
Judo, or conditions of the premises or of any equipment used. Further, I acknowledge that there may be other risks not known
to file or not reasonably foreseeable at this time.

4. Knowing the risks involved in the sport of Judo, I assume all such risks and accept personal responsibility for the
damages following such injury, permanent disability, or death.

5. Release, waive, discharge and covenant not to sue the United States Judo Federation, Inc., United States Judo,
Inc., United States Judo Association, Pa. Judo Inc., Shufu Judo Yudanshakai, Liberty Bell Judo Inc., Liberty Bell Judo Classic,
Liberty Bell Georgian Judo Academy and Academy of New Church, together with their affiliated clubs, their respective
administrators, directors, agents, coaches, and other employees or volunteers of the organization, event officials, medical
personnel, other participants, their parents, guardians, supervisors and coaches, sponsoring agencies, sponsors, advertisers,
and if applicable, owners, lessors, and lessees of premises used in conducting the event, all of whom are hereinafter referred
Zn account of injury, including permanent disability
and death, traumatic brain injury (TBI) or damage to property, caused or alleged to be caused in whole or in part by the
negligence of the Releasees or otherwise to the fullest extent permitted by law.
I HAVE READ THE ABOVE WARNING, WAIVER, AND RELEASE, UNDERSTAND THAT I GIVE UP SUBSTANTIAL RIGHTS BY
SIGNING IT, AND KNOWING THIS, SIGN IT VOLUNTARILY. I AGREE TO PARTICIPATE KNOWING THE RISKS AND CONDITIONS
INVOLVED AND DO SO ENTIRELY OF MY OWN FREE WILL I AFFIRM THAT I AM AT LEAST 18 YEARS OF AGE, OR, IF I AM
UNDER 18 YEARS OF AGE, I HAVE OBTAINED THE REQUIRED CONSENT OF MY PARENT/GUARDIAN AS EVIDENCED BY THEIR
SIGNATURE BELOW.

__________________________________________ _________________________________________ ________________

Participant
W^
Date

FOR PARENTS/GUARDIANS OF PARTICIPANTS OF MINORITY AGE
(UNDER AGE 18 AT TIME OF REGISTRATION)

This is to certify that I, as parent/guardian with legal responsibility for this participant, do consent and agree to his/her release,
as provided above, of all the Releasees, and, for myself, my heirs, assigns, and next of kin, I release and agree to indemnify
and hold harmZ
programs as provided above, even if arising from their negligence, to the fullest extent permitted by law. I have instructed
the minor participant as to the above warnings and conditions and their ramifications.

_________________________________________ __________________________________________ ________________
Parent/Guardian
W'^
U.S. Judo Association, U.S. Judo Federation, Inc., U.S. Judo, Inc.
February 1998
Date
2015 LIBERTY BELL CLASSIC

ATHLETE ENTRY REQUIREMENT CHECKLIST
To assure the requirements for participating in the 28th Annual Liberty Bell Classic, the following
forms must be completed, fully signed, appropriate fees enclosed ($70.00 or $90.00 for Senior
Male Nikkyu & Above and Open Female) and postmarked by March 20, 2015. Late registration
for all forms received on or after March 24, 2015 is $90.00 or $110.00 for Senior Male Nikkyu &
Above and Open Female per division. Entries received without Registration fees will be
considered late entries and will have to pay the late fee.
NO EXCEPTIONS, NO REFUNDS
Mail forms and entry fee to:
Adam and Lou Moyerman

9821 Ferndale St
Philadelphia PA 19115

Please give your postal service time for delivery

&h^&hE^KE>z>:/d
category discounts are for pre-registration only. All foreign checks or money orders in US
funds must be drawn on an American bank or a $5.00 service fee will be assessed per check.
Enclose a self -addressed and stamped envelope if you are interested in checking if your
application is complete.
Entry Fee $90.00 for Senior Male Nikkyu & Above and Open Female divisions. Two division
discount is $115.00 only available for standard registration.
Official Entry Form use correct form Juniors & Youth (ages 5 19), Male Sankyu &
Below/Female Novice, Male Nikkyu & Above/Female Open, or Masters (30 and over).
Anyone competing in two categories must fill out two forms.
Liability Waiver must be signed by contestant and parent/guardian if contestant is under

18 years of age.
o Photo copy of current membership card Athletes must present card at registration. USJI,
USJF, USJA, or national membership card if outside USA are the only acceptable
memberships cards
o Proof of Black Belt Rank copy of rank certificate or USJI card with rank verification symbol
s
Signed certificate regarding non - black belts competing in youth, masters, open female, and
nikkyu and above male.
Parent or athlete signature to certify all information is correct.
*Saturday morning (10:00-11:00 AM at Field House) junior and youth weigh-in requirements:
1. This is a WEIGH-IN ONLY, NO LATE REGISTRATION will be taken Saturday
2. Athletes must be PREREGISTERED AND PAID.
3. Athletes MUST DECLARE THEIR WEIGHT CLASS(ES) ON APPLICATION
4. Athletes MUST MAKE DECLARED WEIGHT CLASS OR BE DISQUALIFIED WITH NO REFUND.

Senior Level Class D

Elite Point procedures:

This event is a USA Judo Senior Class-D the ONLY divisions in which points can be earned are the
SENIOR divisions that include ranks THROUGH black belt. ALL players who place 1 st, 2nd or third
will receive SENIOR points, respectively, and Senior D-level classification. Junior-age athletes
(born 1994 and later) who place 1st, 2nd, or 3rd in those same SENIOR divisions will receive 2.0,
1.0, and .5 JUNIOR points, respectively, on both the IJF Junior and their age-appropriate rosters,
in addition to Senior points.

Restrictions: In order to receive points, players must be citizens of the USA. In addition, players
must win at least 1 match to receive SENIOR points (the 1 win restriction does not apply for
JUNIOR points). All athletes on the USA Judo Junior and Senior Elite Rosters must be current USA
Judo members. In order for an athlete to earn points on the roster, they MUST be a USA Judo
member by the end of the event. If an athlete is not a member by the end of the event, the
athlete will not be eligible for placement on the roster.

Seeding:

For the Elite point categories, the top 4 nationally ranked Senior athletes will be seeded if they
compete in the weight division in which they are ranked. #1 and #4 shall be placed on one side
of the bracket; #2 and #3 shall be placed on the other side. The seeding order shall be in the order

If any of the top 4 nationally ranked athletes are not in attendance, athletes ranked #5 and below
^,>>EKd

Rules for the Elite point categories:

1. /:&'^
2. Players may compete in only 1 division.
3. Players must compete in the weight category that conforms to their measured weight at
weigh-in.
Example: A player competing in the 81 kg division must weigh over 73 kg and less than or equal
to 81 kg. Exception: The Male 55 kg and Female 44 kg divisions are PJU weights and not
KW:h
division may choose to compete in the next higher weight division (Male 60 kg and Female 48
kg).
4. Blue and white judo gis are required.

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THE TWENTY-EIGHTH ANNUAL

LIBERTY BELL JUDO CLASSIC

FRIDAY MARCH 27th

SATURDAY MARCH 28th

IJF Rules will govern, except

New this year!

Seniors & Masters

Junior & Youth

(must mention Liberty Bell Judo)

TOTAL COST in USD ($)

Juniors 12 and Under may fight up one weight category

Division - Please check

Weight Class: __________ weight in kgs only (2.2 pounds = 1 kg)

1. It is mandatory that the enclosed liability waiver be signed in order to participate.

NO PHONE ENTRIES. NO FAX ENTRIES. NO EMAIL ENTRIES. NO REFUNDS.

Division - Please check

Weight Class: __________ weight in kgs only (2.2 pounds = 1 kg)

__________________ _

2015 LIBERTY BELL CLASSIC

Anyone competing in two categories must fill out two forms.

Liability Waiver must be signed by contestant and parent/guardian if contestant is under

Parent or athlete signature to certify all information is correct.

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