http://karatemanitoba.ca Karate Manitoba requires member clubs to complete a membership form of sorts each season in order to help keep information updated. This form is not for individual members, but for INSTRUCTORS. Students should look for the general membership form.

1. 266 Graham Ave
P.O. Box 2519
Winnipeg, MB
R3C 4A7
Application for Club Membership
Membership Year:_______
Administrative Contact
Information will be sent to the person below. This contact information may be changed at any time.
Last Name______________________________________________________ First Name_________________________
Address___________________________________________________City_______________ Province_____________
Postal code__________________________ Phone:______________________ Alt. Phone:________________________
Email Address:_____________________________________________________________________________________
Senior Club Instructor
This is the person who is directly responsible for the technical content of the club's curriculum.
Same as Administrative Contact; or
Last Name______________________________________________ First Name________________________________
Address________________________________________________City___________________ Province____________
Postal code_______________________________ Phone:___________________ Alternate Phone:_________________
Email Address____________________________________________ Club Website______________________________
Date of Birth_________________________ Age____ Gender___ Rank__________
For Karate Manitoba use only:
Received, Membership Officer:______________________________________ Date:_____________________
Board of Directors:________________________________________________ Date:_____________________

2. Club Information
When was the club started: _____________________________________________
Location of club (city or town): ___________________________________________
Address of Club:_______________________________________________________
Street number city/town postal code
Current number of members in club: _________ _________ _________
black belts kyu total
Style Association Information
Style Association refers to a technical organization, style, or association that governs the curriculum
of your club that directs the grading system and provides for examinations and certification.
Does the senior club instructor currently belong to a Style Association that will govern the technical
direction of this club?
Yes; specify _____________________________________________________
No; this club is independent of any such organization.
Is this Style Association recognised by Karate Canada?
Yes
No
CERTIFICATION
NCCP Certification: Respect In Sport Certification: Official’s Certification:
Karate Manitoba/Sport Manitoba
Type:______________ Coach Provincial: Kata level___
#:___________________ Kumite Level___
Level:______________ Date National: Kata level___
(A,B,C,etc) rec’d:__________________ Kumite level____
International: Kata level___
Kumite level____
NEW! In conjunction with Respect in Sport Policy the following items are mandatory. Please provide copy of:
A. Criminal Record Check B. Vulnerable Sector Check C. Child Abuse Registry Check
Karate Manitoba Club fee: $25 (must be included with application)
_____________________________________________ ____________________________________
Signature of Chief Instructor Date
______________________________________________ ____________________________________
Karate Manitoba Membership Director Membership Number