Thailand Open Karate-do Championship 2015

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1 Pre-Pre-Entry Form Please submit by March 31, 2015 Country / Club Name of Federation Address Telephone Fax Will participate Yes No IF YES, PLEASE SPECIFY THE NUMBER OF: Delegation Leader Referee Coach Official competitors Total Date Name of President or Secretary General Signature & Stamp -E1-

2 Entry Form A Please submit by April 30, 2015 Country: Address: Tel: Fax: Federation Participants (please indicate the number of persons only) Chief of Delegation: Team Manager: Officials: Coaches: Referees: Others: Athletes Senior Male: Junior Male: Cadet Male: Senior : Junior : Cadet : Total: Accommodations as prepared by TKF Nights Starting on.. Self arranged accommodations. -E2-

3 Country: Kumite Male//Boy/Girl Entry Form B Athlete s Declaration Last Name: First Name: Attach Photo Here Gender: Male Address: Date of Birth (dd /mm /yy): / / Age: Height (in cm): Weight (in kg): Passport No.: Please make a check in the event you will be participating in: Senior Male 18 & up Senior 18 & up Junior Male Yrs Junior yrs Cadet Male Yrs Cadet yrs Boys/ Girls -55 kg -50 kg -55 kg -48 kg -52 kg -47 kg 12-13yr -60 kg -55 kg -61 kg -53 kg -57 kg -54 kg 10-11yr -67 kg -61 kg -68 kg -59 kg -63 kg +54 kg -75 kg -68 kg -76 kg +59 kg -70 kg -84 kg +68 kg +76 kg +70 kg +84 kg Note: For participants 13 years of age and younger, please enter in the age category that you would be at the time of the competition. Senior Age: 18 & Over (Born before December 31, 1997) Junior Age: 16/17 (Born between January 1, 1998and December 31, 1999) Cadet Age: 14/15 (Born between January 1, 2000and December 31, 2001) Boys/Girls Age: 12/13 (Born between January 1, 2002and December 31, 2003) Age: 10/11 (Born between January 1, 2004 and December 31, 2005) All participants who sign up for the wrong age category will be disqualified from the match. -E3

4 Thailand Open Karate-do Championship 2014 Country: Kata Male//Boy/Girl Entry Form B Athlete s Declaration Last Name: First Name: Attach Photo Here Gender: Male Address: Date of Birth (dd/mm/yy): / / Age: Height (in cm): Weight (in kg): Passport No.: Please make a check in the event you will be participating in: Senior Male 16 & up Senior 16 & up Junior Male Yrs Junior yrs Cadet Male Yrs Cadet yrs Boys/Girls Team Team Note: For participants 13 years of age and younger, please enter in the age category that you would be at the time of the competition. Senior Age: 18 & Over (Born before December 31, 1997) Junior Age: 16/17 (Born between January 1, 1998and December 31, 1999) Cadet Age: 14/15 (Born between January 1, 2000and December 31, 2001) Boys/Girls Age: 12/13 (Born between January 1, 2002and December 31, 2003) Age: 10/11 (Born between January 1, 2004 and December 31, 2005) All participants who sign up for the wrong age category will be disqualified from the match. -E4

5 Country: Team Kata Male Members Names Team Kata; Male/ Entry Form B Athlete s Declaration A Team Kata Male Date of Birth (dd/mm/yy) 1 / / 2 / / 3 / / B Team Kata Male Date of Birth (dd/mm/yy) 1 / / 2 / / 3 / / Please make a check mark on the event that the team will be participating in Team Kata Members Names A Team Kata Date of Birth (dd/mm/yy) 1 / / 2 / / 3 / / B Team Kata Date of Birth (dd/mm/yy) 1 / / 2 / / 3 / / Please make a check mark on the event that the team will be participating in -E5-

6 Non-Liability Form Branch Name: Last Name: Family Name; Attach Photo Here Address; Date of Birth (dd /mm /yy): / / Age; IC Card/Passport No. Sex; M / F I declare that in consideration and condition of my entry in the Championships for myself, my heirs, executors administrators, I hereby waive all and any claims, right or cause of action, which I or they might otherwise have, arising out of any injury, loss of life of any description whatsoever which I may suffer, sustain in the course of participating or consequent upon my entry or participation in the above Championships. This waiver, release and discharge, which shall be binding on my heirs, executors administrators, and shall be and shall operate separately in favor of all persons, corporations and bodies involved or otherwise engaged in organizing this Championships tournament and the servants, agents, representatives and officers of any of them. I confirm to the organizers of the Championships that I have in place either personal accident or medical insurance. Competitor Signature: Date; To be completed by both Parents/Guardians (If under 18 years of age) I and being the parent(s)/guardian(s) (Print the 1 st Parent/Guardian s Name) (Print the 2 nd Parent/Guardian s Name) Of confirm that my child is a minor. (Print Competitor s Name) In consideration of the Association accepting my child s application to enter and complete in the tournament. I acknowledge that participation in the tournament carries the risk that personal injury may occur and I/we jointly and severally agree to indemnify the Association against any claims, suits or demands or any nature whatsoever whether in tort or contract or otherwise for any loss or damage or injury whatsoever to my child however caused or occurring including without limiting the foregoing, the negligence, breach of contract, willful act or default of the Association, its servants, employees, agents, representatives, officers or any of them or my child s opponent, arising out of or in the course of my child s entry into or participation in this competition. I confirm to the organizers of the Championships that I have in place either personal accident or medical insurance that also covers my child. 1 st Parent/Guardian Signature: Date; 2 nd Parent/Guardian Signature: Date; In the event that any provision or part of a provision of these conditions is held or found to be void. Invalid or otherwise Unenforceable it shall be deemed to be served from the conditions to the extent of such Invalidity or unenforceability but the remainder of the conditions shall remain in full force and effect. -E6

7 Hotel Reservation Country Hotel Room Number Check-in Check-out Single Double Triple (No EB) Triple (w/eb) For Hotel Booking Purposes Country Club Name Of Delegation Representative Address Tel Credit card No Expiry Date Type of card Fax -E7

8 Hotel Reservation Country Person-in-charge of Delegation Address Zip Code Telephone Fax No. No. Family Name Given name Position* Check-In Date Checkout Date No. of Nights Total (USD) Grand Total *Position: CO-Coach, VIP President/Head of Delegation, O Team manager-official/staff, A Athlete, R Referee/Judge, M/P Media/Press -E8

9 Flight Information Country ARRIVAL Arrival Date Arrival Time Flight Number City of Departure Number of Persons Transport (Airport to Hotel) Required Not Required DEPARTURE Departure Date Departure Time Flight Number City of Destination Number of Persons Transport (Airport to Hotel) Required Not Required -E9

10 Term of Responsibility To be filled, signed and returned by June 30th, 2015 I, the undersigned, as the chief of Delegation of my team, duly enrolled to participate in the Thailand Open Karate-do Championships 2014, which will be held in Bangkok, Thailand from July 26 th -30 th, 2015, with full knowledge of the Statues, the Rules and the Norms of the ASIAN KARATE FEDERATION, pledge myself to faithfully accomplish the regulations of this before mentioned entity, and I take any and all administrative, civil and criminal responsibilities for whatever happens to our athletes, coaches and other members of our delegation participating in this championship, before, during and after the competition, such as physical injuries, personal expenses, or monetary debts and casual material damages to the hotels, the venue, means of transportation, etc. Furthermore, I exempt from any legal, civil or criminal responsibilities the organizers of the Championships, the Thailand Karate Federation, its directors, as well as any person, company, or entity related to the event (sponsors, public and private entities). I authorize the organizers of the event to use images, photos and the names of our competitors and other members of our delegation (since it is considered necessary) for the sport activities and publications of karate, related to the event, without any monetary compensation. Country/Nation : Surname, First name: Passport number & expiry date: Credit card details & expiry date: Position in the federation: Address: Tel.-no.: Fax & Fill in, stamp, sign and send to: Thailand Karate Federation The Organizing Committee of the Thailand Karate-do Championships 2014 Bangkok. 286, the Sport Authority of Thailand Room 237, Rachamangkara Stadium, Ramkhamheng Rd. Bangkok Thailand Tel: Fax: Signature & Stamp: Please fill out this form and send it back to the Thai Karate Federation on or before June 30, 2015 Fax:

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