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Central Zone Regional Tournament th ENTRY Sunday, March 4 , 2012 Cocks Moors Woods Leisure Centre.

Alcester Rd Sth, Birmingham B14 6ER

Please complete both pages of this form in full and pass it in to your local instructor along with the entry fee. Thank you!


Name: Address: Region: Dojo:

Age at time of completion:

Phone: Karate Grade: GRADE DIVISION th th 8 to 7 Kyu th th th 6 , 5 & 4 Kyu rd 3 Kyu & Above

AGE GROUPS Up to 7 yr Incl. Male & Female 8 to 9 yr Incl. Male & Female 10 to 11 yr Incl. Male 10 to 11 yr Incl. Female 12 to 13 yr Incl. Male 12 to 13 yr Incl. Female 14 to 15 yr Incl. Male 14 to 15 yr Incl. Female 16 to 17 yr Incl. Male 16 to 17 yr Incl. Female Jnr Open Black Belt Male (14 17 yrs)* Jnr Open Black Belt Female (14 17 yrs)* 18 to 34 yr Incl. Male (up to 1st kyu) 18 to 34 yr Incl. Female (up to 1st kyu) Open Black Belt Male (18 yrs+)** Open Black Belt Female (18 yrs+)** 35 to 44 yr Incl. Male 35 to 44 yr Incl. Female 45 to 54 yr Incl. Male 45 to 54 yr Incl. Female 55 yr + Male 55 yr + Female Instructors Male Instructors Female



TEAM EVENTS th Junior Team Kata 8 4 Kyu (under 18 yrs) rd Junior Team Kata 3 Kyu+ (under 18 yrs) Team Kata Male (18+ yrs) Team Kata Female (18+ yrs) Male Team Kumite (18+ yrs) Female Team Kumite (18+ yrs) TEAM NAMES Kata Team 1 2 3 Kumite Team 1 2 3 4 5

* 14 - 17 yrs Black Belts MUST enter Junior Open Division. ** 18 - 34 yrs Black Belts MUST enter Open Division. ** Both red & blue GKR /WKF mitts are required for Open division competitors


Protective equipment is compulsory for Kumite
Note: GKR/IGKF or WKF certified RED or BLUE mitts are now COMPULSORY for age groups 12/13 yrs & up. Either colour is acceptable except Opens div.
> Shin protectors & Mouth Guards must be worn by all competitors. > Groin guards for all male competitors is compulsory. > Chest protectors are compulsory for all female competitors from 12 years.

Fee Paid: Sensei Sign: Sensei Name:


1. 2. I am aware that participation in martial arts, including non-contact GKR tournaments, as with most sports contains a risk of injury. In consideration of my acceptance in the competition, I agree that GKR Karate, its servants and agents and all persons involved in the organisation of the tournament shall be excluded from liability for loss and damage to the fullest extent permitted by law. I accept that this includes exclusion of liability for negligence (other than for death or personal injury) and all indirect or consequential loss or loss of profits arising from participation in the tournament


Parents Signature:
(If under 18 years of age)

Name: Address:


Post Code: Phone Number: Other Number:

Please circle YES or NO to the following questions and statements. Do you have any allergies? e.g. aspirin; antibiotics; foods? Have you been in contact with any contagious diseases in the last 3 months? Are you taking any form of medication at present? YES YES YES NO NO NO

If the answer is YES to any of these questions, please give details:

Doctors Details: Name: Address: Phone Number:

Emergency Contact Details: Please give two contact numbers where someone can be contacted in the event of an emergency 1. Name: Phone Number: 2. Name: Phone Number: Relationship: Other Number: Relationship: Other Number:

Declaration (Delete as applicable) I / My son / daughter is capable of taking part in the GKR Karate Tournament. I am willing to allow my son / daughter to participate in the above activity and confirm that they will be attending the tournament with / without a parent / guardian / a nominated person who has agreed to supervise my child. In the event of illness or injury, I agree to authorise members of staff attending / participating in the event to consent on my behalf for an anaesthetic to be administered or any other urgent medical treatment to be given on the advice of a qualified medical practitioner / qualified first-aid officer.

Signed: Name (please print):



Cocks Moors woods Leisure Centre Alcester Rd South, Birmingham 8.00am: Competitor Check In 9.30am: Tournament Commences
Competitor Entry Fees: 12.00 first event, 6.00 each subsequent event Spectators: Adult 5, Child 3, Family 12 (children under 5 years free) Closing date for entries: Sunday, February 26, 2012 (5 late fee will apply) NO ENTRIES WILL BE ACCEPTED ON THE DAY All fees are strictly non refundable Competitors Safety Equipment
Note: GKR/IGKF or WKF certified RED or BLUE mitts are now COMPULSORY for age groups 12/13 years & above. Either colour is acceptable, except in Open divisions where competitors will require both colours.

Mouth guards and standard white shin protectors, are compulsory. Chest protectors are compulsory for all female competitors 12 years+. Groin Protectors are compulsory for all male competitors.

NB: 1. Competitor to keep this page for tournament details. 2. Competitor must hand in entry form along with fees to instructor.

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