2009 SOUTH EAST QLD STATE CHAMPIONSHIP QUALIFIER
KARATE QLD MEMBER PAYMENT - BEFORE YOU COMPLETE ENTRY FORM PLEASE MAKE PAYMENT BY CLICKING HERE (form will not be accepted without payment)
KARATE QLD NON MEMBER PAYMENT - 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 31ST DECEMBER 2008
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
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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
KUMITE
KATA
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Which division do you wish to enter:
Junior Female (18-21)
Junior Male (18-21)
Senior Male 70 Kg and Under
Senior Male Over 70 KG
Senior Female 60 Kg and Under
Senior Female Over 60 KG
Veteran Male
Veteran Female
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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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I AM COMPLETING THIS FORM FOR
MYSELF
MY STUDENT - I understand I must forward to Karate Qld Condition of Entry form signed by Parent/Guardian prior to competition
CLICK HERE to Download Condition of Entry/Consent form
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I AGREE TO ALL OF THE TERMS AND CONDITIONS SPECIFIED FOR THIS TOURNAMENT FOR MYSELF OR MY CHILD OR CHILD UNDER MY GUARDIANSHIP
Conditions of Entry 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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