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Are you a new or renewing member?Karate BC # (if applicable) Lookup

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Dojo *

Tournament Experience *

Athlete Phone * - International Number

Athlete Email * Opt in to emails

Parents Name *

Parents Phone * - International Number

Parents Email * Opt in to emails

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This registrant is competing in a team kata ONLY.

Division

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Waiver items are required for this registration. If you do not have legal rights to complete waiver items on behalf of the registrant please enter the email address of the registrant or parent/guardian (if the registrant is under the age of majority). ?

I am registering myself or I am the parent/guardian of the registrant or I have legal rights to complete waiver items on behalf of this registrant *

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Email address to send waiver to *

I have read and agree
INDIVIDUAL LIABILITY WAIVER- MANDATORY for All Karate Competitors

Acknowledgment and Release

By his/her signature below, the Tournament Competitor ('Competitor') or Parent/Guardian if under 19, acknowledges that he/she has read the 'Note to Karate Competitors' above, and that the requisite information required in this form has been disclosed. Tile Competitor expressly confirms that he/she has disclosed all illnesses, injuries, ailments, symptoms, or medical conditions of any kind whatsoever suffered or sustained by the Competitor as requested in the Medical Examination Report. It is also understood that the Competitor will consult his/Iler physician for a physical examination should an examination be requested by the Tournament Medical Director.

Furthermore, the Competitor hereby releases Yoshiaki Sato, Vancouver Shitoryu Satokai, Shitoryu Satokai Association of Canada and their employees, agents, successors, assigns, directors or volunteers from any and all liabilities arising out of or connected with any loss, damage, injury or expense suffered or sustained by the Tournament Competitor as a consequence of or in connection with his/her participation in the Tournament Competition or any activity related thereto.

Results from this event may be published in media.

I have read and agree to the above *

Instructor Name *

Address *

Dojo Name *

*Privacy Disclosure

Medical and personal information contained within will be available for review by members of the Association's Medical committee and their assistants. In the event of injury, a competitor's information may be shared with health care

providers assisting that athlete. Signing this form gives consent to said use of a competitor's personal information.

MEDICAL EXAMINATION REPORT

Part A – MANDATORY COMPLETION by all KUMITE competitors

1. Have you any disease of the eyes? *

Yes No

2. Do you have a hearing loss? *

Yes No

3. Do you have fainting spells, blackouts or epilepsy? *

Yes No

4. Have you had a head injury within the past year? *

Yes No

5. Do you have bronchial asthma? List treatment below *

Yes No

6. Do you have any active lung infection including TB? *

Yes No

7. Do you have any heart disease or high blood pressure? *

Yes No

8. Do you have an active kidney disease, infection or failure? *

Yes No

9. Do you have any loss of all or part of a limb? *

Yes No

10. Do you have decreased movement in any limb, joint or spine? *

Yes No

11. Do you have any muscle or joint disease? *

Yes No

12. Do you have diabetes? *

Yes No

13. Do you have hepatitis, AIDS/HIV or any other blood borne disease? *

Yes No

14. Are you taking any medication? *

Yes No

15. Do you have allergies to any medications? *

Yes No

16. Have you had any recent operations, fractures or major illness? *

Yes No

17. Do you have any disease or disability not mentioned above? *

Yes No

If you answered “Yes” to any of the above questions, give details and obtain medical clearance from your physician to compete. (Information provided not confidential)

Waiver agreement

I hereby declare that I have read the above information and that, to the best of my knowledge, it is complete and correct.

I have read and agree to the above *

MEDICAL EXAMINATION REPORT - Part B – to be completed by examining physician if “YES” was answered on any questions in Part A DOWNLOAD HERE

Typed digital signature (type your name exactly as entered above "registrants name") *

Parent/guardian digital signature *

25th Annual Sato Cup

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Division

Acknowledgment and Release

*Privacy Disclosure

MEDICAL EXAMINATION REPORT

Waiver agreement

Please fix the following errors:

Division

Acknowledgment and Release

*Privacy Disclosure

MEDICAL EXAMINATION REPORT

Waiver agreement

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