Club/Instructor Application Form: Karate Manitoba 2012-2013

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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.

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Club/Instructor Application Form: Karate Manitoba 2012-2013

  1. 1. 266 Graham Ave P.O. Box 2519 Winnipeg, MB R3C 4A7 Application for Club Membership Membership Year:_______Administrative ContactInformation 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 InstructorThis is the person who is directly responsible for the technical content of the clubs curriculum. Same as Administrative Contact; orLast 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. 2. Club InformationWhen was the club started: _____________________________________________Location of club (city or town): ___________________________________________Address of Club:_______________________________________________________ Street number city/town postal codeCurrent number of members in club: _________ _________ _________ black belts kyu totalStyle Association InformationStyle Association refers to a technical organization, style, or association that governs the curriculumof 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 technicaldirection of this club? Yes; specify _____________________________________________________ No; this club is independent of any such organization.Is this Style Association recognised by Karate Canada? Yes NoCERTIFICATIONNCCP Certification: Respect In Sport Certification: Official’s Certification: Karate Manitoba/Sport ManitobaType:______________ 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

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