Judge Seminar and Practical Clinic

Judge Seminar and Practical Clinic

Friday June 12, 2011

Seminar 10:00am—11:30am

Practical Clinic—2:00pm—3:00pm

Cost: $20 (for both) if pre-register by May 1, 2011

$25 Pay at door

Open to CampParticipantsOnly

This Class is mandatory for all JKA W/F America members currently holding judge qualifications (for renewal purposes) and optional for any black belt member interested in obtaining a judge qualification in the future. You must be a Dan rank JKA/WF member and a registered camp participant to attend this event.

Judge Seminar & Practical Clinic Registration

Name ______Age______DOB ______Sex Rank ______

Address______City______State ______Zip ______

Region ______Country ______

Dojo ______Tel ( )______Email ______@______

Are you JKA/WF America member?Yes / No

Are you a registered JKA/WF Instructor or Instructor Trainee?Yes / NoQualification Rank ______

Payment Form: amount enclosed $______

Mail with $20.00(US) payment to: NMKA c/o JKA/WF America, P.O. Box 95215, Albuquerque, NM 87199

2011 JKA/WF America National CampRegistration Form

Name ______Age______DOB ______Sex Rank ______

Address______City______State ______Zip ______

Region ______Country ______

Dojo ______Tel ( )______Email ______

Are you JKA/WF America member?Yes / No

Are you a JKA/WF member?Yes / No

Are you a registered JKA/WF Instructor or Instructor Trainee?Yes / NoQualification Rank ______

Do you have a JKA Passport?Yes / No

Every member must have a JKA/WF Passport or Membership Card. If you do not have one please obtain one through your regional office. If you have further questions about obtaining a passport you may contact the administrative office.

JKA/WF America National Camp 2011 T-shirt Order Form:

In order to guarantee your T-shirt, you must pre-order and include payment with pre-registration. We may not guarantee availability or size at National Camp. Pre-order postmarked deadline: May 1, 2011. No shirts will be pre-ordered without payment in advance.

Attendees who prepay IN FULL before May 1, 2011 will receive only $10 T-shirt. Please indicate size below.

Price per shirt: Pre-ordered $20.00 (US) / At Camp $25.00 (US) - subject to availability T-shirt sizes: Youth S, M, L Adult S, M, L, XL and XXL

Dojo name:______Country ______

Name______Size __Qty __Amount Enclosed $_____

Payment Form:

Mail with $50.00(US) deposit to: NMKA c/o JKA/WF America, P.O. Box 95215, Albuquerque, NM 87199

Camp Deposit/Tuition (from page 2) $_____

T-shirt (total amount) $_____

Total$_____

All fees are due in US currency. Please make check or money order payable to: NMKA

All JKA/WF America members that are brown and black belts must have their JKA/WF passport with them at camp. All other members must have their JKA/WF America membership card or passport.

Participant’s Medical Questionnaire and Waiver on page #5 must be completed and signed.

Children must be accompanied by an adult or guardian at all times. Each dojo is responsible for enforcing this policy for their students.

Participant's Medical Questionnaire & Waiver:

To be completed by all adults and guardians of minors attending JKA/WF America Camp or Tournament 2011

Name ______Date of Birth ______Sex ______Rank ______

Address______City______State _____ Zip ______

Region ______Country ______Dojo ______

Do you have a history of any of the following conditions? Please check either yes or no for each one.

If you answer yes to any, please explain:

Yes No

______Heart murmur

______Hypertension

______Recent infection

______Bone fracture in the past six months

______Concussion or severe head injury in the past six months

______Seizures

______Eye injury

______Severe bone bruises requiring padding

______Kidney injury

______Allergy to medication (list all):

______Any other medical conditions affecting your physical activity. If yes please specify ______

______Are you currently taking any medications? If yes please specify ______

Other______

______

Signature of Participant (Parent or Guardian if under 18 years of age)Date

Waiver/Release Agreement: PLEASE INITIAL AND SIGN WHERE INDICATED

Japan Karate Association/World Federation America National Camp 2011, I understand that there are risks and dangers inherent in martial arts training and in participating in and/or receiving instruction at the EVENT. I understand and agree that by signing this Waiver/Release, I am assuming full responsibility for any and all risk of personal injury or death or for property damage suffered by me while participating in and/or receiving instruction at the EVENT. I expressly acknowledge that my participation in the EVENT may subject me to personal injury or bodily harm and I assume any and all risks of that participation. I also understand that in order to be allowed to participate in and/or receive instruction at the EVENT, I must give up my rights to hold Japan Karate Association World Federation America and its affiliates, and all other clubs, schools, instructors, members, judges, officials, representatives and all other participants (collectively the "Releases") liable for any injury or damage which I may suffer while participating in and/or receiving instruction at the EVENT. _____Initial

I also understand and agree that by signing the Waiver/Release, I acknowledge that I am solely responsible for having or obtaining all insurance coverage which may be necessary or desirable in connection with my participation in and/or receipt of instruction at the EVENT and for any travel to and from the EVENT and in all lodging or any other activities which may be related directly, indirectly or incidentally to the foregoing. ____Initial. I further understand and agree that any fees or costs required for necessary or requested medical attention shall be my sole responsibility and that I shall not seek indemnification or contribution from any Release in connection therewith. I also understand that the Releases shall not be responsible for any incidental, consequential or exemplary damages of any kind even if they are notified of the possibility of such in advance. I also understand and agree that any damage to any lodging sites or the tournament site that I cause is my full responsibility. In no case are said damages the responsibility of any of the Releases. I further understand and agree that as consideration for my participation in the EVENT, Japan Karate Association World Federation America and or its designees shall have the right to use my name, image or likeness in the promotion of the EVENT or in any publication relating to the EVENT (or similar Events) and in any broadcast or rebroadcast transmission of the EVENT without any additional consideration to me for the use of my said name, image or likeness. ____Initial

I understand and agree that this Waiver/Release will have the effect of releasing, discharging, waiving and forever relinquishing any and all actions or causes of action that I may have or have had, whether past, present or future, whether known or unknown, and whether anticipated or unanticipated by me, arising out of my participation in and/or receipt of instruction at the EVENT. ____Initial

Knowing this, and in consideration of being permitted to participate in and/or receive instruction at the EVENT, I hereby release and agree to indemnify and hold harmless the above-named Releases individually and their entities, and their officers, agents, principals, partners, shareholders, directors and employees from any and all liability or costs, including attorney fees, associated with or arising from my participation in and/or receipt of instruction at the EVENT. I further understand and agree that this Waiver/Release will be binding on me, my spouse, my heirs, my personal representative, my assigns, my children and any guardian ad litem for said children. ____Initial

I understand that if I am signing this Waiver/Release on behalf of my minor child, that I will be giving up the same rights for said minor, as I would be giving up if I signed this document on my own behalf. ____Initial

I acknowledge that I have read this Waiver/Release Agreement and that I understand the words and language in it. ____Initial

Print Name Date ______

Sign Name ______Witness ______

P10

JKA/WF America______Request for_Dan and Qualification Testing ______

Testing for: ______Dan Rank Qualification Rank JudgeInstructor Examiner

(D C B)(D C B) (D C B)

Please type or print clearly.

Name ______Date of Birth _____/_____/_____ Age ____ Gender M F

Address______City______State____ Zip ______Country ______

Telephone ( ) ______Fax ( ) ______Email______

Dojo Region ______Present Rank (dan) ______

I plan to take the following examination (s):

Examination / Current Rank (if any) / Date of Last exam / If you have previously tested for this next rank, please list dates of each previous exam. If this is your first time testing for this rank, please list “first time”.
Dan
*Judge
*Instructor
*Examiner

Record of existing qualifications: JUDGE/INSTRUCTOR/EXAMINER/

Judge Qualifications Instructor Qualifications Examiner Qualifications

Date of Exam Registration Number Date of Exam Registration Number Date of Exam Registration Number

D ___/___/______D ___/___/______D ___/___/______

C ___/___/______C ___/___/______C ___/___/______

B ___/___/______B ___/___/______B ___/___/______

If you are planning to take the next level exam and already have qualification in any of these areas, you must provide proof of your currentqualifications. If you do not have a qualification passport, you must obtain one from your region before testing.

If you are taking the Dan examination please list previous Dan registration numbers (if applicable):

Rank / Registration / Date of Exam / Chief Instructor/Examiner's name
Sho
Ni
San
Yon
Go
Roku

If you are a JKA/WF America member and want to take the Dan test you must have a current JKA/WF AMERICA passport. You will be charged $70.00 (US) for a replacement passport.

I PROMISE THAT THE ABOVE INFORMATION IS COMPLETE AND ACCURATE AND I WILL CONTINUE TO UPHOLD THE STANDARDS AND HONOR OF JKA AND JKA/WF AMERICA.

Signature Date______

P11

REQUEST FOR DAN REGISTRATION JKA/WF America

For the purposes of clarity all information must be typewritten. Handwritten forms will be returned.

Name ______

Address ______photo

______

Telephone (_____) ______Email ______

Registering for ______DanDate of Examination ______

Examiner ______Instructor ______

**Instructor’s Signature ______**

Club Name ______Country ______Region ______

Personal information

Date of Birth ____/____/_____ Sex M ____ F____ Height _____ft-_____in-_____cm Weight ______lbs/kg

Occupation ______

LastSchool or College ______Degree ______

KARATE HISTORY

When did you begin karate practice? Year ______Month ______

Previous Dan Registrations:

Date of ExamReg. No.Date of ExamReg. No. Report

Sho (1) Dan______Go (5) Dan______y/n

Ni (2) Dan______Roku (6) Dan______

San (3) Dan______

Yon (4) Dan______

I REQUEST THAT MY RANK BE LISTED IN THE REGISTER OF THE JAPAN KARATE ASSOCIATION/WORLD FEDERATION. I PROMISE TO UPHOLD THE STANDARDS AND HONOR OF JKA/WF.

Student’s Signature ______

FOR EXAMINER’S USE ONLY

Rank Awarded ______Examiner’s Signature ______

Promotion by: (circle one)EXAMINATIONRECOMMENDATION HONORARY

Remarks:

P12

REQUEST FOR QUALIFICATION REGISTRATION JKA/WF America

For the purposes of clarity all information must be typewritten. Handwritten forms will be returned.

**A separate form must be filled out for each Qualification**

Name ______

Address ______photo

______

Telephone (_____) ______Email ______

Registering for (circle one) JudgeInstructorExaminerDate of Examination ______

(D C B)(D C B)(D C B)

Examiner ______Instructor ______

**Instructor’s Signature ______**

Club Name ______Country ______Region ______

Personal information

Date of Birth ____/____/_____ Age____Sex M ____ F____ Height _____ft-_____in-_____cm Weight ______lbs/kg

Occupation ______

LastSchool or College ______Degree ______

KARATE HISTORY

When did you begin karate practice? Year ______Month ______

Previous Qualifications:

Judge Qualifications Instructor QualificationsExaminer Qualifications

Date of Exam Registration Number Date of Exam Registration NumberDate of Exam Registration Number

D ___/___/______D ___/___/______D ___/___/______

C ___/___/______C ___/___/______C ___/___/______

B ___/___/______B ___/___/______B ___/___/______

I REQUEST THAT MY RANK BE LISTED IN THE REGISTER OF THE JAPAN KARATE ASSOCIATION/WORLD FEDERATION. I PROMISE TO UPHOLD THE STANDARDS AND HONOR OF THE JKA/WF.

Student’s Signature ______

FOR EXAMINER’S USE ONLY

Rank Awarded ______Examiner’s Signature______

Promotion by: (circle one)EXAMINATIONRECOMMENDATION HONORARY

Remarks:

P13

JKA/WF America National Camp 2011

Remittance Checklist

Please return this checklist with your registration. Make copies of all paperwork for yourself. Do not email forms.

Name:______Region:______

CampParticipants

Registration form______*

Waiver signed______*

T-shirt ordered______(optional)

Payment included ______*Amount enclosed US$______

JKA/WF membership card or passport yes__/no___ (DO NOT MAIL)Check Payable to: NMKA

(Do NOT mail in card/passport, required to show at camp registration)

If you do not have a card or passport, please obtain one from your region before camp or pay the non-member fee.

*Mandatory items

Dan Examinees

All camp requirements (see above)______*

Dan testing form—typed______*

Dan Registration form- typed (2 copies)______*

Two passport photos______*

Copy of previous rank certificate______*

Dan Registration fee payment (separate check)______*Amount enclosed US$______

Dan Examination fee payment______*Amount enclosed US$______

Report (Godan Testing only)______*All exam checks payable

JKA/WF America Passport______* (DO NOT MAIL)to: JKA/WF America

(Do not mail in passport. You will be required to show passport at exam)

* Mandatory items must be submitted by May 1, 2011 or you will not be allowed to test at the June Camp.

Qualification Examinees

All Camp requirements______*

Copies of previous qualifications______*

Copy of Latest Dan certificate______*

Qualification testing form—typed______*

Qualification Registration form typed (2 copies)______*

Qualification Exam Fee payment______*Amount enclosed US$______

Qualification Registration fee payment (separate check)______*Amount enclosed US$______

2 Copies Trainee Report (D Instructor examinees only)______*All exam checks payable

2 Copies Completed Instructor Trainee technical subject sheetto: JKA/WF America

(D Instructor examinees only)______*

2 Copies of CPR certification ______*

(D Instructor examinees only)

*Mandatory items must be submitted by May 1, 2011 or you will not be allowed to test at the June Camp.

Even if items have already been submitted, they must be submittedagain with CampRegistration packet.Total Remittance US$______

Mail to:Please make all Camp checks payable to: NMKA (New Mexico Karate Association)

JKA/WF America Administrative OfficePlease make all exam and rank registration checks payable to: JKA/WF America

P.O. Box 95215

Albuquerque, NM87199

P14

Selection of Judges Form

Judges must meet the requirements as established by the JKA/WF America. JKA/WF America Technical Committee shall designate the Chief Judge and Arbitrator. A minimum of three (3) judges is requested from each region.

This is to confirm that the following persons will serve as Judges at the 2011 JKA/WF America National Karate Tournament and National Collegiate Tournament. A minimum of two (2) judges, rates C or above, is required from each region.

Each participating judge must present his or her current JKA/WF issued License Qualification card.

Region: ______

NameDan RankJudge’s RankCertificate #

(A, B, C, D)

______

Signature of Regional Director:______

This information must be postmarked no later than May 1, 2011

ALL JUDGES MUST SHOW VALID JKA QUALIFICATION CARD

Please send to:JKA/WF America

P.O. Box 95215

Albuquerque, NM87199

P15

Adult Individual Black Belt Regional Representative Seeding Form

Each region may send the top competitors from that region’s elimination tournament as “previously qualified contestants” for the National Tournament. The number of competitors in each event is as follows:

Women’s Kata (4) Women’s Kumite (4) Men’s Kata (4) Men’s Kumite (4)

All contestants must pre-register, and all registrations must be postmarked by May 1, 2011.

Contestants must be at least 18 years of age, 3rd kyu and over, and must present a current JKA/WF Passport at check-in.

Registration fees are non-refundable. A single event is $45 ($35 with paid camp fee) or both events are $55 ($45 with paid camp fee) per contestant.

Region:______

Regional Director’s Signature:______

Men’s Kumite:

______

Women’s Kumite:

______

Men’s Kata:

______

Women’s Kata:

______

Total amount enclosed:$______

Please make checks or money orders payable to:NMKA

JKA/WF America

P.O. Box 95215

Albuquerque, NM87199

P17

Black Belt Adult Individual Division Tournament Registration Form

All contestants must pre-register, and all registrations must be postmarked by May 1, 2011. Contestants must be at least 18 years of age and must present a current JKA/WF membership passport at check-in. Please submit a signed Medical Questionnaire & Waiver (page10) for each individual.

Registration fees are non-refundable. A single event is $45 ($35 with paid camp fee) or both events are $55 ($45 with paid camp fee) per contestant. There are no limits to the number of contestants from one region.

Region:______

Amount

NameRankSexAgeKataKumite Enclosed

______

Total amount enclosed: $______

Please make checks or money orders payable to:NMKA

Please send to:JKA/WF America

P.O. Box 95215

Albuquerque, NM87199

P18

Brown Belt Adult Individual Division Tournament Registration Form

All contestants must pre-register, and all registrations must be postmarked by May 1, 2011. Contestants must be at least 18 years of age and must present a current JKA/WF Passport at check-in. Please submit a signed Medical Questionnaire & Waiver (pg 10) for each individual.

Region:______

Amount

NameRankSexAgeKataKumite Enclosed

______

Total amount enclosed: $______

Please make checks or money orders payable to:NMKA

Please send to:JKA/WF America

P.O. Box 95215

Albuquerque, NM87199

P19

Adult Regional Team Registration Form

Each region may send one team for each of the following team events.

Men’s Team Kumite, Women’s Team Kumite, Men’s Team Kata, Women’s Team Kata

All teams must pre-register, and all registrations must be postmarked by May 1, 2011.

Contestants must be at least 18 years of age, 3rd kyu and over, and must present a current JKA/WF Passport at check-in. Team registration $100 per team. Please submit a signed Medical Questionnaire & Waiver (pg 10) for each individual. Registration fees are non-refundable.

Region:______

Regional Director’s Signature:______

Men’s Team Kumite:NameRank

(Captain)______

______

(Alternate)______

Women’s Kumite:

(Captain)______

______

(Alternate)______

Men’s Kata:

(Captain)______

______

(Alternate)______

Women’s Kata:

(Captain)______

______

(Alternate)______

Total amount enclosed:$______

Please make checks or money orders payable to:NMKA mail to: P.O. Box 95215 Albuquerque, NM87199

P20

Senior Individual Division Tournament Registration Form

All contestants must pre-register, and all registrations must be postmarked by May 1, 2011. Contestants must be at least 45 years of age, 3rd kyu or higher rank, and must present a current JKA/WF Passport at check-in. Please submit a signed Medical Questionnaire & Waiver (pg 10) for each individual.

Region:______

Amount

NameRankSexAgeKataKumiteEnclosed

______

Total amount enclosed: $______

Please make checks or money orders payable to:NMKA

Please send to:JKA/WF America

P.O. Box 95215

Albuquerque, NM87199

P21

Senior Team Kata Registration Form

Each region may send one kata team for the Senior Team Kata Event. Teams may be a mix of male and female.

All teams must pre-register, and all registrations must be postmarked by May 1, 2011.

Contestants must be at least 45 years of age, 3rd kyu or higher, and must present current JKA/WF Passport at check-in. (must be US member)

Team registration $75 per team. Registration fees are non-refundable. Please submit a signed Medical Questionnaire & Waiver (page 10) for each individual.

Region:______

Regional Director’s Signature:______

Senior Team Kata:NameRank

(Captain)______

______

(Alternate)______

Total amount enclosed:$______

Please make checks or money orders payable to:NMKA

Please send to:JKA/WF America

P.O. Box 95215

Albuquerque, NM87199

P23

Collegiate Tournament Individual Registration Form

All contestants must pre-register, and all registrations must be postmarked by May 1, 2011. Contestants must be at least 18 years of age, full time undergraduate college students only; no part-time or graduate students will be allowed to compete. Proof of enrollment and current JKA/WF membership must be presented at check-in. Please submit a signed Medical Questionnaire & Waiver (page 10) for each individual.