SEIDO JUKU KARATE AUSTRALIA
2014 National Benefit Tournament – Application Form
Date: Saturday 15th November 2014from 9am – 4pm; Venue: King George V Recreation Centre
- General Information:
Name: ______/ Middle Initial: ______/ Last Name: ______
Streeet Address: ______/ City: ______/ State: ______/ Postal Code: ______
Email Address: ______/ Phone (H): ______/ (M): ______/ (W): ______
Birthdate: ______/ Age: ______/ Male / Female / Height: ______/ Weight: ______
Branch: ______/ Country:______/ Instructor: ______
Belt Rank/Kyu Grade:______/ Internationl Membership #: ______
Junior / Senior: ______/ School (Juniors Only): ______
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B. National Benefit Tournament
I wish to participate in the following events (circle then number of your events according to your rank and age group):
EVENTS / ELIGIBLE RANKS AND/OR AGE GROUPS- TECHNIQUE / SHIAI (SHADOW KUMITE)
- INDIVIDUAL KATA - (S)
- WEAPONS KATA - (S)
- TEAM KATA
- INDIVIDUAL KUMITE (POINT SYSTEM) - (S)
- DEMONSTRATION EVENT: INDIVIDUAL KUMITE (CONTINUOUS)
- TEAM KUMITE
- BREAKING - (S)
Notes: Please refer to the 2014 Tournament Rules. All divisions may be adjusted to reflect the number of competitors. Black Belts must participate in the events markeed (S) to be considered for the SOGO Championship.
Single Event / AUD$35.00 AdultsAUD$25.00 Juniors / $
Two Events / AUD$50.00 Adults
AUD$35.00 Juniors / $
Three + Events (Note: individual and team kumite are separate events) / AUD$60.00 Adults
AUD$40.00 Juniors / $
Tameshiwari Boards / AUD$5.00 / Board
No of Boards _____ / $
Spectator Fee / AUD$8.00 Adults
AUD$5.00 Juniors / $
All boards will be provided to competitors at AUD$5.00/board.
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C. Pre-Ordered Merchandise:
I would like to pre-order the following merchandise (circle your choices):
2014 Australian National Tournament T-Shirt (Mens) / S/M/L/XL/XXL / White or Navy / AUD$30.00 / $2014 Australian National Tournament T-Shirt (Womens) / S/M/L / AUD$30.00 / $
2014 Australian National Tournament T-Shirt (Kids) / 8/10/12/14 / AUD$25.00 / $
Seido Karate Australia – Official Sports Bag / Red w/ Black / AUD$45.00 / $
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D. Tournament Sponsorship or Benefit Donation:
I would like to sponsor part of the tournament or make a charitable donation (circle your choice):
Tournament Sponsor / Medals/Awards / Venue / $Tournament Donor / Cancer Council Australia / Youth Off the Streets / $
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E. Summary & Payment Details:
Subtotal – Section B: National Benefit Tournament / $Subtotal – Section C: Pre-Ordered Merchandise / $
Subtotal – Section D: Tournament Sponsorship / Benefit Donation / $
Total: / $
Please process payment against the following credit card details:
Visa / M/C / Number: ______/ Expiry Date: ______(circle one) / Signature: ______
Note: A 1.5% merchant fee will apply for all credit card payments.
Instructions: Send a softcopy to no later than Monday, 27th October 2014. Penalties: A $10 penalty will be added to any applications received after the 27th October 2014.
Pre-Ordered Merchandise: If an application is received after the 27th October, pre-ordered merchandise may not be available on the day of the Tournament.
Refund Policy: If you need to cancel your attendance at the Tournament event for which you have already registered and paid, you must do so byMonday, 3rd November 2014. We cannot refund payment for cancellations after this time.
Enquiries:Please contact Kyoshi Leigh Maquirang at for further information.
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The applicant warrants, represents and acknowledges that he/she is fully aware of the nature and risks involved in the Seido Juku Karate Australia National Benefit Tournament and he/she is physically and mentally fit to participate in such activity. The applicant further agrees that in consideration for being permitted to participate, he/she assumes the risk of any and all accidents and injuries of any kind sustained by him/her by reason of, or in connection with, said Tournament activities. The applicant hereby releases, discharges and absolves SEIDO JUKU KARATE, its agents and employees of any and all liability and responsibility for any accidents or injuries, whether the same are caused by or attributed to their negligence or the negligence of any of them. The applicant further agrees to assume the risk of any accident or injury of any kind sustained anyplace in the building where said Tournament is held, or on entering or leaving such building and hereby releases, discharges and absolves SEIDO JUKU KARATE, its agents and employees of any and all liability and responsibility for any accidents or injuries, whether the same are caused by or attributed to their negligence or the negligence of any of them. The applicant warrants and acknowledges that he/she has read the Tournament rules and regulations and agrees to abide by them. The applicant fully understands that any medical treatment given will be of first aid type only. The applicant consents to the use of, and waives any compensation whatsoever for, all pictures, movies, tapes, TV, media coverage, etc. by SEIDO JUKU KARATE or those designated by them.
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AGREED ON: 20
SIGNATURE OF APPLICANTSIGNATURE OF PARENT OR LEGAL GUARDIAN
(REQUIRED FOR APPLICANTS UNDER 18)