Champion of Champions Online Entry Form
....... BEFORE YOU COMPLETE ENTRY FORM PLEASE MAKE PAYMENT BY CLICKING HERE .......(form will not be accepted without payment)
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NAME
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ADDRESS
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POSTCODE
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PHONE
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EMAIL
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DATE OF BIRTH
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GENDER
MALE
FEMALE
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AGE AS AT 4TH OCTOBER 2008
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Please note: If competitor does not turn 18 until after due date, parent/guardian must sign and complete Conditions of Entry form.
18
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WHAT GRADE IS THE COMPETITOR
10TH KYU
9TH KYU
8TH KYU
7TH KYU
6TH KYU
5TH KYU
4TH KYU
3RD KYU
2ND KYU
1ST KYU
BLACK BELT
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NAME OF YOUR KARATE CLUB
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INSTRUCTORS NAME
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INSTRUCTORS CONTACT NUMBER
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ARE YOU COVERED BY PERSONAL ACCIDENT INSURANCE FOR THIS TOURNAMENT
As a condition of entry you must or your club must have personal accident insurance for every competitor entered. Please note this insurance must be specific to Karate.
YES
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NAME OF INSURANCE COMPANY WHO WILL COVER YOU IN THIS TOURNAMENT
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WHICH EVENT DO YOU WISH TO ENTER
MALE KUMITE
FEMALE KUMITE
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DO YOU HAVE ANY ILLNESS OR INJURY THAT MAY AFFECT YOU COMPETING
YES
NO
IF YES PLEASE ATTACH COPY OF MEDICAL CLEARANCE FROM MEDICAL PRACTITIONER
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PLEASE LIST 3 OF YOUR PERSONAL BEST ACHIEVEMENTS IN KARATE TOURNAMENTS
CURRENT PHOTO OF YOURSELF
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I AGREE TO ALL OF THE TERMS AND CONDITIONS SPECIFIED FOR THIS TOURNAMENT
Terms and Conditions can be downloaded from:
http://www.akfqld.com.au/Conditions%20of%20Entry.pdf
YES
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I HAVE READ AND AGREE TO KARATE QUEENSLAND PRIVACY AND DISCLAIMER
Privacy and Disclaimer can be downloaded from:
http://www.akfqld.com.au/AKFQ%20PRIVACY%20AND%20DISCLAIMER.pdf
YES
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NAME OF PERSON COMPLETING THIS FORM
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Indicates Response Required
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