PERSATUAN KOSHIKI KARATE-DO PERAK

PERAK ASSOCIATION OF KOSHIKI KARATE-DO

42, Persiaran Bandar Baru Tambun 15,
Taman Ipoh Impian, 31400 Ipoh.
Tel./Fax: +605-5499320

(NON - LIABILITY FORM)

2017 MALAYSIA OPEN KOSHIKI CHAMPIONSHIP

NAME OF COUNTRY / FEDERATION / ASSOCIATION / CLUB:
NAME:

DATE OF BIRTH:

PASSPORT NO.:
HEIGHT (CM):

SEX:
WEIGHT (KG):

RANK / TITLE:

ADDRESS:

E-MAIL ADDRESS:

MOBILE PHONE NO.:

T- SHIRT SIZE:

EVENT:

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
Karate-do Association as the main organizer and its official bearers will not be blamed or responsible 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
Date:

PLEASE
SUBMIT 2
PHOTOS
(PASSPORT
SIZE)

Parent / Guardian Signature

(If below the ages of 18 years old)
Name:...
Relationship:.

[CLOSING DATE: 15/06/2017]