UNICON XII Registration: Fuyuki Tsuchiya
UNICON XII 登録： 土屋 冬樹

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Steps left to complete registration:最終手続き

1. Verify the registration details.(登録内容の詳細を確認してください)
2. Print out this page.（このページを印刷してください）
3. Sign the release below and hand in at registration desk at UNICON.Minors (under 20) need to have parent or guardian signature.(署名については日本在住の日本人登録者には日本文での署名をお願いしていますのでこのページの英文での署名は必要ありません。)
4. Send payment by wire transfer in the amount of \16000 plus \2500 per wire transfer (to cover transfer charges on receiving end) to:（海外登録者には銀行振り込みをお願いしておりますが、日本在住の日本人登録者には郵便振替でお支払いいただくようにお願いしています。振替用紙は全種目出場確定後に、協会本部より振替用紙をお送りいたします。）

   Mizuho Bank, Branch #49
   3-2-4 Kitaaoyama, Minatoku, Tokyo
   
   Savings account number: 2444820
   Swift Code: MHBKJPJT
   Account Name: Japan Unicycling Association
   You specified Mayumi Sakaino as the party that will send the wire transfer.

Refund Policy:キャンセルについて

Refund requests received prior to April 1, 2004 will be granted in full. Refund requests received between April 1, 2004 and June 21, 2004 will be granted 50%. Refund requests received on or after June 21, 2004 will not be granted. All refund requests must specify the desired currency (US dollars, Euros, Yen, etc.). If the currency is not specified on the form the refund will be made in Japanese yen. Refunds made in other than Japanese yen will have the cost of currency exchange deducted. All refunds will be at the current exchange rate in Tokyo, at the time the refund request is processed.
4/1以前のキャンセルについては全額返金
4/2-6/20 のキャンセルについては50％返金
6/21以降は返金しません。
海外選手につきましては、要望があれば、換金手数料の本人負担で、返金通貨の種類を指定できます。指定のなかったものは日本円で返金します。

Contact Information 連絡先

Events Registration
Japan Unicycling Association
Toyu Bldg. 3F, 3-52-8, Sendagaya, Shibuya-ku,
Tokyo, 151-0051, JAPAN
Phone: +81-3-3497-1048 (in Japan: 03-3497-1048)
Fax: +81-3-3479-5913 (in Japan: 03-3479-5913)
Website: http://www.unicon12.com/

For more information, please contact:

Mayumi Sakaino
JUA-IC
Tokyo, JAPAN / JAPAN Time (GMT plus 9 hours)
Fax: +81-3-3479-5913
E-mail: unicon12@japanunicyclingassociation.org

Registrant: (Online Registration #777)
登録者: （オンライン登録番号 No.777）

Competitor Registration: 登録競技

Racing:レース

Category: Maximum 24" wheel, age 13+
出場クラス：24インチ車

Event(s)：出場登録されているレースの全種目が記載されます．
100m, 400m, 800m, 50m one foot, 30m wheel walk, obstacle course
10k Standard, Road gliding,

Artistic:演技

Standard Skill: Yes
標準技術：出場

Individual Freestyle: Expert
個人演技：エキスパートクラス

Pairs Freestyle: Expert (Partner: Makiko Nakano)
ペア演技：エキスパートクラス（パートナー名）

Group Freestyle: yes (Group: KYOKAI)
グループ演技：出場の場合YES（グループ名）

Other Events:その他の種目

Basketball: yes （Team:Japan Basket A Team）
バスケットボール：出場（チーム名）

Hockey: No
ホッケー：不参加

Downhill MUni: No
ダウンヒル：不参加

Uphill MUni: No
アップヒル：不参加

Cross Country MUni: Yes
クロスカントリー：出場

Trials Course: Yes
トライアル：出場

Expenses: 費用/支払額

UNICON XII Release（UNICON XIIでの責任について）
日本在住の日本人登録者向けには参加同意書の提出をお願いしていますので、この英語版は提出する必要がありません。

The organizers of the Twelfth International Unicycling Convention and World Championships (UNICON XII) remind all participants that unicycling is a potentially hazardous activity. The organizers of UNICON XII cannot accept responsibility for any personal injury which you might sustain or cause to another person as a result of participation in any of the events. Additionally, the organizers are not responsible for theft or loss of, or damage to, personal property.

All participants are required to sign the following statement:

In consideration of the International Unicycling Federation, Inc.; Kasumigaoka National Stadium; Yoyogi National Stadium Second Gymnasium; Sendagaya Elementary School; Tokyo Metropolitan Yoyogi Park Sports Ground; Fujimi Panorama Resort; National Olympics Memorial Youth Center; Arakawa River Bed Biki Path; Japan Unicycling Association (JUA); International Unicycle Federation (IUF); Ministry of Education, Culture, Sports, Science and Technology; Tokyo Metropolitan Board of Education; the metropolitan area of Tokyo; and Nagano prefecture; and, all other sponsors, agents, and representatives organizing and conducting UNICON XII from July 23th to August 2nd, 2004, and allowing me to participate in said event, I hereby waive, release, and discharge forever all above said organizations and their sponsors, agents, and representatives from all claims, demands, actions and causes of action of whatsoever kind and nature arising directly from any known or unknown, foreseen or unforeseen, bodily and personal injury, damage to property, and consequences thereof resulting from my participation in said UNICON 12. I assume all risks of injury or mishap resulting from my participation and covenant, not to sue the aforementioned parties for said injuries and / or damage. I also permit the International Unicycling Federation, Inc. and the Japan Unicycling Association to provide, furnish, or engage emergency medical treatment to me or my said son or daughter. I also give permission for the use of my name and / or picture in any broadcast, telecast, or other account of this event.

Signature__選手本人のサイン欄（自筆）__________________     Date____________________
          (Fuyuki Tsuchiya)

I give my consent for the above named to attend UNICON 12 on the above terms.

Parent/Guardian Signature____保護者のサイン欄 （自筆）_     Date____________________