PERSATUAN KOSHIKI KARATE-DO NEGERI PERAK

[PERAK KOSHIKI KARATE-DO ASSOCIATION, MALAYSIA] 42, Persiaran Bandar Baru Tambun 15, Taman Ipoh Impian, 31400 Ipoh, PERAK. MALAYSIA Telephone / Fax: (6)05-5499320 E-mail: koshikiperak@yahoo.com

(NON - LIABILITY FORM) MALAYSIA / PERAK KOSHIKI KARATEDO OPEN CHAMPIONSHIP - 2013
NAME OF ASSOCIATION & COUNTRY: NAME: N.R.I.C. NO.: HEIGHT (CM): RANK / TITLE: WEIGHT (KG): ADDRESS: DATE OF BIRTH: SEX: T/SHIRT SIZE:

EVENTS:

I as the above wish to participate the Championships / Activities at my own risks and I shall solely responsible for the injuries that I may sustain during the Championships / Activities either internally or externally and I undergo the programs / events at my own risks. I am fully aware that the Perak Koshiki Karatedo Association as the main organizer and its official bearers will not be blamed or responsibled for any unexpected incidents might be happened. I, my family and whoever either related to me or none related to me shall take the blame to the organizer of the above events and programs.

Participant Signature

PLEASE SUBMIT 2 PHOTOS (PASSPORT SIZE)

Parent / Guardian Signature (if below the ages of 18 years old) Name:... Relationship:.