Dojo Administration

1

Personal Information

First name *

Last name *

Address *

Suburb

State

Post code

Phone number *

Email *

Date of birth *

Current grade

2

Emergency Contact

Emergency contact name *

Emergency contact relationship

Emergency contact phone *

3

Terms & Conditions

I hereby agree to participate in the required physical activities and exercises as required during the course of the seminar at Holdfast Bay Community Centre/Brighton Karate conducted by Ysobel Jarjoura, Ruben Rubio and Pamelia Tungkasiri /Central Coast Kyokushin Karate and Brighton Karate on the basis of the terms and conditions set out below:

1. I hereby acknowledge an understanding of and agree to participate in physical demanding activities that if done incorrectly could be detrimental to my health.

2. I acknowledge that the training, while conducted in the safest possible conditions and under qualified supervision, involves physical contact and inherent risks and I accept those risks. I agree to conduct myself in a safe and mature manner in accordance with the instructions from my instructors. I indemnify Brighton Karate and Central Coast Kyokushin Karate, Pamelia Tungkasiri, Ruben Rubio and Ysobel Jarjoura, its proprietors, agents and officers, and Matsushima Kyokushin Australia Inc. (NSW) including all instructors, staff members, and students against any loss or damage suffered by them in connection with my participation in the training.

3. I confirm I am physically capable of participating in this training and that I have no existing medical condition which precludes or should reasonably preclude my participation.

4. I agree to release Brighton Karate and Central Kyokushin Karate, Pamelia Tungkasiri, Ruben Rubio and Ysobel Jarjoura, its proprietors, agents and officers, and Matsushima Kyokushin Australia Inc. (NSW) including all instructors, staff members, and students from any liability whatsoever in connection with my participation in the required physical activities and exercises within the Fight Like a Champion Karate Workshop. Without limitation, this includes all loss or damage or injury incurred as a direct or indirect result of my participation.

5. I agree that I will conduct myself in an appropriate manner and will always act in a manner that is in the best interests of Brighton Karate and Matsushima Kyokushin Australia Inc. (NSW)

6. By participating in this event and during this event only, if I am not already a member, I agree that I become a member of Matsushima Kyokushin Australia Inc. (NSW).

I have read and agree to the terms and conditions above. *

4

Physical Readiness Questionnaire

The required training and exercises within this Seminar consists of, but not limited to the following: karate techniques, kihon (basics), kata (forms), kumite (sparring), pad work, conditioning exercises, stretching, and fitness drills. Participants are required to complete the questionnaire below as a prerequisite before starting the course for assessment of any special needs and/or considerations.

#	Question	Yes / No
1	Has your doctor ever said you have a heart condition or vascular disease?	Yes No
2	Do you ever experience chest pains?	Yes No
3	Have you experienced any chest pain recently?	Yes No
4	Do you ever feel faint, dizzy, lose balance or lose consciousness?	Yes No
5	Has your doctor ever said you have high blood pressure (140/90)?	Yes No
6	Are you taking any medication for blood pressure or a heart condition?	Yes No
7	Are you a male over 35 or, a female over 45 and not accustomed to exercise?	Yes No
8	Do you have a bone or joint problem that could be made worse by a change in your physical activity?	Yes No
9	Do you suffer from asthma?	Yes No
10	Do you suffer from any other respiratory problems?	Yes No
11	Do you suffer from diabetes?	Yes No
12	Do you suffer from epilepsy?	Yes No
13	Do you currently suffer from any illness not mentioned here?	Yes No
14	Do you know of any other reason why you should not participate in physical activity?	Yes No

If you have answered Yes to any question, you may be required to provide a doctor's certificate before participating.

Do you suffer from any allergies? Please specify:

To the best of my knowledge I have answered the questions above truthfully. I understand and agree that it is my responsibility to inform Brighton Karate instructors Pamelia Tungkasiri or Ruben Rubio of any conditions or changes in my health, now and on going, which might affect my ability to participate safely in required exercises.

5

Signature (Applicant)

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Name (applicant) *

Date *

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Signature (Parent or Legal Guardian)

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Name (parent or legal guardian)

Date