Athlete Information
First Name
Last Name
Gender
Male
Female
Date of Birth (YYYY/MM/DD)
Level/Rank
10 Kyu
9 Kyu
8 Kyu
7 Kyu
6 Kyu
5 Kyu
4 Kyu
3 Kyu
2 Kyu
1 Kyu
1 Dan
2 Dan
3 Dan
4 Dan
5 Dan
6 Dan
7 Dan
8 Dan
9 Dan
10 Dan
Email Address
Address
City
Province
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Québec
Saskatchewan
Yukon
Postal Code
Home Phone
Competition Info
Weight (kg) (Mandatory for Kumite) (Optional)
Height (Optional)
Experience (years) (Optional)
Style
Select One
Chito-Ryu
Goju-Ryu
Shito-Ryu
Shotokan
Uechi-Ryu
Wado-Ryu
Kyokushin
Other
Sensei
Dojo
Events
Kata
Kumite
Para
Kata/Kumite
Goal/Interest
Team Tryout
Open Sessions
Emergency Contact
First Name
Last Name
Relationship (Optional)
Please Select One
Mother
Father
Grandparent
Aunt
Uncle
Sibling
Babysitter/Nanny
Spouse/Partner
Phone (Cell)
Phone (Home) (Optional)
Alternate Email (Optional)
First Name (Secondary Contact) (Optional)
Last Name (Secondary Contact) (Optional)
Relationship (Secondary Contact) (Optional)
Please Select One
Mother
Father
Grandparent
Aunt
Uncle
Sibling
Babysitter/Nanny
Spouse/Partner
Phone (Secondary Contact) (Optional)
Email (Secondary Contact) (Optional)
Health Information
Health Card #
Expiry Date
Extended Health Insurance Company Name (Optional)
Policy # (Optional)
ID # (Optional)
Have you ever had a concussion?
Yes
No
(If yes, explain: how many, dates and severity) (Optional)
List medical conditions you have and medications you are on (Optional)
