2015 Australian Kung-Fu Wushu Championships
2015 Australian Kung-Fu Wushu Championships 3rd May 2015 Ryde Community and Sports Center Kent Road Ryde, NSW Conducted by Kung Fu Wushu New South Wales KWNSW officially recognised by the Kung Fu Wushu Australia as the peak governing body for Kung Fu (Wushu) in New South Wales KWA officially recognised by the Australian Sports Commission as the peak governing body for Kung Fu (Wushu) in Australia TABLE OF CONTENTS GENERAL INFORMATION ......................................................................................................1 ROUTINE COMPETITION RULES AND REGULATION .........................................................3 SPARRING COMPETITION RULES AND REGULATION.......................................................7 APPLICATION AND ASSESSMENT FORM FOR DEGREE OF DIFFICULTY OF OPTIONAL TAOLU ................................................................................................................11 CERTIFICATE OF FITNESS (SANDA FULL CONTACT) .....................................................12 SEROLOGY REPORT (SANDA FULL CONTACT) ...............................................................17 APPLICATION INDEMNIFICATION WAIVER FORM TO PARTICIPATE .............................18 i 2015 Australian Kung-Fu Wushu Championships GENERAL INFORMATION 1. Championship Date rd Sunday 3 May 2015 9:00 am – 5:00pm (Registration 8:30am) The Championship Organising Committee reserves the right to make changes to the programme which are deemed fit. 2. Championship Venue Ryde Community and Sports Center Kent Road Ryde, NSW 3. Competitors Qualification For Entry (a) Only members of Kung Fu Wushu Australia’s State Associations are eligible to participate in the Championships. (b) Competitors must submit the required documentation and pay the designated fees (refer to Championship Fees and Registration) 4. Registration (a) Internet Sign Up System will be adopted. The competitors shall fill out online Entry Forms and make payment via the Internet. (b) Website for Internet Registration System: http://www.2015nationals.eventbrite.com.au (c) Closing date for internet registration is Friday, April 3 2015. (d) Competitors must also submit the completed and signed Waiver Form by the registration closing date and email to [email protected] (e) Any competitor who has registered online and also supplied the required documentations by the required dates will be entered into the Championships. (f) No changes or additional entries will be accepted after the deadline. (g) Refunds only issued in special cases and will be subject to administration costs as decided by the Championship Organising Committee. (h) All competitors are required to check-in on the day of their event. Any competitor who does not check-in by within 30 minutes of their event may be forfeited to compete and entry monies will be retained by KWA: 5. Australian National Wushu Team Selection (a) The following wushu taolu and wushu sanda events will be used to select the 2015 - 2016 Australian National Wushu Team: Youth / Adult Optional Taolu with Nandu Youth / Adult Traditional Taolu (Xingyiquan, Baguazhang, Dadao or Shuangjian only) rd Youth / Adult Compulsory Taolu (Hand Form only and must be the 3 International Competition Routine) Adult Sanda Events (b) Competitors wanting to be considered for the Australian National Wushu Team must submit the Application for Australian National Wushu Team Selection. Information on how to register can be found on www.kungfuwushuaustralia.com (c) Applicants must fulfil the eligibility requirements stated in the Application for Australian National Wushu Team Selection to be considered for the Australian National Wushu Team. 1 6. Championship Fees First individual routine or sparring event Second individual routine or sparring event Duel routine event Group routine event Australian Dollars KWA Members $45 per person $15 per person $15 per person $10 per person 7. Travel and accommodation All travelling expenses (eg. air fare and transportation), accommodation, tours and sightseeing are at own expense. 8. Anti-Doping Policy All competitors must comply with the KWA Anti-Doping Policy which can be viewed at www.kungfuwushuaustralia.com therefore agreeing to any random drug testing as requested by the Australian Sports Drug Agency. 9. Enquiries For further information and enquires regarding the Championship, please contact: General Enquiries: Email: [email protected] Unacceptable Behaviour Disciplinary Procedures The KWA has a zero tolerance policy towards unsportsmanlike, disruptive and unprofessional behaviour. Competitors will be immediately disqualified from this event for conduct which the Chief Referee of that event considers to be unsportsmanlike, disruptive or unprofessional. This conduct may include, but not be limited to, cheating, dishonesty, failing to comply with the reasonable directions of a competition official, jeering, interference with the activities of competition officials, publicly criticising judges' decisions outside the appeals process laid down in this documents and any other form of behaviour likely to bring the sport into disrepute. In the event of a complaint about the conduct of a competitor, the Chief Referee must be notified ASAP of the incident. It is the Chief Referee's responsibility to advise the competitor, on the spot, that he/she will be disqualified. Other persons may be expelled from the event for conduct which the Chief Referee finds unacceptable. 2 ROUTINE COMPETITION RULES AND REGULATION 10. Championship Events and Age Divisions Age Divisions Child 7 to 12 years old Junior 13 to 15 years old Youth 16 to 18 years old Adult 19 to 45 years old Senior 46 years and above Note: Age is based on the competitor’s birthday during the championship year. Kung Fu Events Bare Hand: Northern Style (Northern Shaolin, Northern Praying Mantis, etc) Southern Style (Jow Gar, Hung Gar, Choy Li Fut, White Crane, Wing Chun, Bak Mei, Ging Mo Kune, etc) Other Style (Xing Yi Quan, Ba Gua Zhang, Ba Ji Quan, etc) Weapon: Long Weapon Short Weapon Other Weapon (Flexible, Double Weapons, etc) Wushu Taolu Events Bare Hand: Nandu Events (Youth and Adult Age Group only) - Optional Changquan - Optional Nanquan - Optional Taijiquan - Non-Nandu Events Changquan Nanquan Taijiquan Baguazang Xingyiquan Weapon: Nandu Events (Youth and Adult Age Group only) - Optional Daoshu - Optional Jianshu - Optional Gunshu - Optional Qiangshu - Optional Nandao - Optional Taijijian Non-Nandu Events Daoshu Jianshu Gunshu Qiangshu Nandao Taijijian Dadao Shuangjian Tai Chi Events Bare Hand: Compulsory Routines - Yang Style Taijiquan - Chen Style Taijiquan - 36 Step Taijiquan (3rd Set Competition Routine of Taijiquan) 3 New Routines - 24 Step Taijiquan - 42 Step Taijiquan - Yang Style Competition Routine - Chen Style Competition Routine Traditional Routines - Yang Style - Chen Style - Wu Style - Sun Style - Wu (Hao) Style - Other Style Weapon: Compulsory Routines - Yang Style Taijijian - Chen Style Taijijian - 39 Step Taijijian (3rd Set Competition Routine of Taijijian) New Routines - 32 Step Taijijian - 42 Step Taijijian Traditional Routines - Yang Style Sword - Chen Style Sword - Wu Style Sword - Sun Style Sword - Wu (Hao) Style Sword - Other Style Sword - Other Weapon (Fan, Broadsword, etc) Duel Events Choreographed sparring sets of Bare Hand to Bare Hand, Weapon to Weapon or Bare Hand to Weapon Note: Championship Organising Committee has the power to merge any division or events if insufficient number of competitors for any division or events occurs. A photocopy of your current Prohibited Weapon License must accompany your Championship Entry Form if your events involve any weapons prohibited in New South Wales. You must also bring your license on the day of the Championship. For more information on what weapons are prohibited in NSW, please go to: https://www.police.nsw.gov.au/__data/assets/pdf_file/0018/133191/Prohibited_Weapo ns_Schedule1_April_2012.pdf 11. Participation Methods Each routine competitor may enter at most: one bare-hand event one weapon event one duel event one group event for a maximum of 4 (four) events Duel event is limited to 2-3 persons. Male and female mixed teams are not allowed. In group events, teams shall consist of no less than 6 persons and no more than 10. Male and female competitors can be mixed. Each participating organisation may only enter one group team. 4 12. Relevant Rules (a) Routine Events – Kung Fu, Tai Chi, Duel and Group The Kung Fu and Tai Chi events shall be individual competition. The competition rules for Kung Fu, Tai Chi, Duel and Group will be based on the “Rules for Internationa Taolu Competition” endorsed by IWUF in 1999. These rules can be obtained at www.kungfuwushuaustralia.com Music should be accompanied to the group routine. CD shall be brought by the participating teams. No lyrics are allowed, otherwise 0.20 points will be deducted by the head judge. The head judge will deduct 0.20 points if the group performs without music. The power of interpretation of the Rules rests solely with the Chief Judge. (b) Routine Events – Wushu The competition shall be individual competition. The competition rules for Wushu will be based on the “Rules for International Taolu Competition” endorsed by IWUF in 2005. These rules can be obtained at www.kungfuwushuaustralia.com Optional Taolu with Nandu - The Scoring Criteria for Events with Specific Requirements for Degree of Difficulty will be implemented. - Competitors are required to submit the Registration Form for Movements with Degree of Difficulty by for all of their events and emailed to [email protected] Non-nandu taolu events - The Scoring Criteria for Events without Specific Requirements for Degree of Difficulty will be implemented. Music must be accompanied to Optional Taijiquan and Optional Taijijian. Lyrics are not permitted. 0.2 point will be deducted if there is no music accompanied to the said routines. The power of interpretation of the Rules rests solely with the Chief Judge. 13. Time Requirements for Routine Events (a) Kung Fu Events: Bare hand and Weapon routines: Not less than 40 seconds and not more than 1 minute and 30 seconds. (b) Wushu Events Changquan, Nanquan and Weapon routines: Adult and Youth Age Group: Not less than 1 minute and 20 seconds and not more than 1 minute 30 seconds. Child, Junior and Senior Age Group: No time limit. Taijiquan and Taijijian routines: Not less than 3 minutes and not more than 4 minutes. And NO warning bell will be given. Xingyiquan, Baguazhang, Dadao and Shuangjian routines: Not less than 1 minute and not more than 2 minutes. (c) Tai Chi Events All new routines and traditional hand routines: 5 to 6 minutes. Warning bell given at 5:30. All new routines and traditional weapon routines: 3 to 4 minutes. Warning bell given at 3:30. Group routines: 4:30 to 5 minutes. Warning bell given at 4:30. (d) Duel Events: Not less than 40 seconds and not longer than 1 minute and 30 seconds. 5 (e) Group Events Not less than 2 minutes and not longer than 5 minutes. 14. Competitors Costume, Uniform, Foot Wear & Equipment (a) Wushu Taolu events Competitors must wear wushu taolu competition costume in compliance with the “Rules for International Taolu Competition” as endorsed by IWUF in 2005 to participate in the competition. Martial arts style athletic or any rubber-soled sports shoes/sneakers must be worn (performance with bare feet is not allowed). Competitors shall bring their own competition weapon for their own respective events. Jewellery, including watches may not be worn. Nails must be clipped short and metal hair clips are also not to be worn. No heavy metal, body piercing, earrings or rings. If a ring cannot be removed, it must be taped. Note: Failure to comply with these rules will result in disqualification from their event. (b) All other routine events Kung Fu Costume: traditional kung-fu costume, or official Academy / Club / School martial arts uniform. Tai Chi Costume: traditional tai chi costume or official Academy / Club / School martial arts uniform. If the competitor has no costume or uniform, a plain T-shirt, track pants and a sash must be worn. Martial arts style athletic or any rubber-soled sports shoes/sneakers must be worn (performance with bare feet is not allowed). Competitors shall bring their own competition weapon for their own respective events. Jewellery, including watches may not be worn. Nails must be clipped short and metal hair clips are also not to be worn. No heavy metal, body piercing, earrings or rings. If a ring cannot be removed, it must be taped. Note: Failure to comply with these rules will result in disqualification from their event. 15. Placing and Awards The top three places for each event will be awarded as follows: 1st Place 2nd Place 3rd Place Gold Medal Silver Medal Bronze Medal 6 SPARRING COMPETITION RULES AND REGULATION 1. Championship Events and Age Divisions (a) Controlled Contact Sparring Events Age Divisions 7 – 8 years old 9 – 10 years old 11 – 12 years old 13 – 15 years old 16 – 18 years old 19 – 35 years old 36 to 55 years old Note: Age is based on the competitor’s birthday during the championship year. Weight Classes: Men and Women: below (kg): 36, 40, 44, 48, 52, 56, 60, 65, 70, 75, 80, 85, 90, over 90kg Championship Organising Committee has the power to merge any divisions if insufficient number of competitors for any divisions occurs. (b) Sanda Full Contact Sparring Events Age Divisions Youth 16 to 18 years old Adult 19 to 35 years old Note: Note: 2. 3. Age is based on the competitor’s birthday during the championship year. Weight Classes: Men and Women: below (kg): 36, 40, 44, 48, 52, 56, 60, 65, 70, 75, 80, 85, 90, over 90kg Championship Organising Committee has the power to merge any 2 neighbouring division or events if insufficient number of competitors for any division or events occurs. Participation Methods Each competitor may register and compete in both controlled contact sparring and sanda full contact sparring events. Each competitor may only enter in 1 (one) weight category. Relevant Rules (a) Controlled Contact Sparring Events All techniques must be controlled contact. The elimination system will be adopted. If the number of competitors in a weight category is only 3 (three), a round robin will be adopted. The competition will be based on the “KWA Controlled Contact Sparring Rules”. These rules can be obtained at www.kungfuwushaustralia.com Each bout will be one (1) round. The competition time for each round will be two (2) minutes for 19 years and above and one (1) minute thirty (30) seconds for 18 years and under. A competitor exiting / falling out of the arena twice in a round will lose the round. The power of interpretation of the Rules rests solely with the Chief Judge. 7 Legal Target Areas Torso above the waist including front and side. - Thighs, inside and outside of thigh area and the leg below the knee. Prohibited Areas of Attack Any part of the head. - Any part of the neck; - The groin. - The back (spine). - The knees, elbows and other joints. Legal Techniques: 7–8 yrs 9 – 10 yrs 11 – 12 yrs 13 – 15 yrs 16 – 18 yrs 19 – 35 yrs 35 – 45 yrs Clinching (max two seconds only) Sweeps and takedowns Throws that will not cause injury Punches to the body Kicks to the body and legs Kicks to the inside and outside of thigh area Prohibited Methods: Striking to the head whether making contact or as a feint. - Head butt, forearm, elbow and knee strikes or arm locks and similar joint-locking techniques. - Throws that could result in a head, neck or spine injury or throws which cause a competitor to land awkwardly on the head, neck, spine, shoulder, knee or joints or throws with a falling height from above shoulder level. - Intentionally smashing or pressing him down. - Hitting the opponent’s head by any means when he is already down. - Choke or strangling techniques. - Grappling or wrestling on the mats. - Grasping an opponent with one or two hands and striking with the other hand or kicking. - Pushing the opponent for more than 1 metre or off the arena. - All prohibited techniques which are deliberately intended to injure the opponent rather than to score points are whether on target or not. The consideration will be judged on what would have happened if the opponent was struck by the technique. (b) Sanda Full Contact Sparring Events The competition shall be Full Contact. 8 The elimination system will be adopted. If the number of competitors in a weight category is only 3 (three), a round robin will be adopted. The competition will be based on the “KWA Sanda Sparring Rules”. These rules can be obtained at www.kungfuwushaustralia.com The competition time for each round shall be 2 minutes for adults and 1 minute 30 seconds for youths. Each bout will be the best of three (3) rounds. A competitor exiting / falling out of the arena twice in a round will lose the round. The power of interpretation of the Rules rests solely with the Chief Judge. Legal Target Areas Any part of the head except the back of the head. 4. - Torso above the waist including front and side but excluding the back. - Thighs, inside and outside of thigh area and the leg below the knee. Prohibited Areas of Attack The back of the head. - Any part of the neck. - The groin. - The back (spine). - The knees, elbows and other joints. Legal Techniques: Hand, leg techniques, takedowns and sweeps which are not listed as a prohibited technique may be used to attack any legal target area. Prohibited Methods: For youth sanda events, kicks to the head as well as successive/continuous punches to the head are not permitted. - Head butt, forearm, elbow and knee strikes or by arm locks and similar joint-locking techniques. - Takedowns by sweeps and throws that could result in a head, neck or spine injury or throws which cause a competitor to land awkwardly on the head, neck, spine, shoulder, knee or joints or throws with a falling height from above shoulder level. - Intentionally smashing or pressing him down. - Hitting the opponent’s head by any means when he is already down. - Choke or strangling techniques. - Grappling or wrestling on the mats. Competitors Costume, Uniform, Foot Wear & Equipment (a) Controlled Contact Sparring Events Competitors must wear and bring their own gloves, cotton shin protectors, cotton instep protectors and mouth guards. Gloves will be either red or black. The weight of the gloves will be 230 grams (8 oz) for men 65kg category & under, women of all weight categories and juniors (18 years and under) of all weight categories. The weight of the gloves will be 280 grams (10 oz) for men 70kg category & above. 9 Male competitors must wear and bring their own groin guard. All groin guards must be worn under the uniform pants. Groin guards are optional for female competitors. Adult female competitors must wear and bring their own approved chest protector. Each competitor must wear his/her traditional martial arts school uniform consisting of shirt or singlet and long pants or shorts, pertaining to his or her school and in good condition. No street clothes are permitted. The head judge will have the final say as to whether any clothing is or is not acceptable in competitions. Note: Failure to comply with these rules will result in disqualification from their event. (b) Sanda Full Contact Sparring Events Competitors shall wear costumes and protective gears in compliance with the “Rules for International Sanshou Competition” as endorsed by IWUF in 2005 to participate in the competition. Each competitor must bring their own two (2) sets of costumes: one set of black and one set of red costumes. Gloves and protective gear will be provided by the Organizing Committee except for gumshield and jockstrap which will be provided by the competitors themselves. Note: Failure to comply with these rules will result in disqualification from their event. 5. Weighing-in Controlled Contact Sparring Events The weighing-in will take place on the day of the Championships at the Championship venue at 8am. Sanda Full Contact Sparring Events The weighing-in will take place on the day of the Championships at the Championship venue at 830am. 6. Competitors are required to submit a KWA Certificate of Fitness and Serology Report. These must be issued within 30 days before the Championships and signed by a qualified doctor. This will be submitted during weigh-in. Placing and Awards All Sparring Events The top three places for each event will be awarded as follows: 1st Place 2nd Place rd 3 Equal Place Gold Medal Silver Medal Bronze Medal(s) 10 APPLICATION AND ASSESSMENT FORM FOR DEGREE OF DIFFICULTY OF OPTIONAL TAOLU Association: ________________________________________________________________ Name: _____________________________Surname:_______________________ Male/Female Degree of difficulty for movements, and connections 1 ST SEGMENT 2ND SEGMENT 3RD SEGMENT 4 Event:______________________ TH SEGMENT TOTAL VALUE Transitions Movements Signature of Coach Contact Info Movement Code 11 Certificate of Fitness (Sanda Full Contact) PART ONE – To be completed by the examining medical practitioner Full Name of the Sanda Contestant ________________________________________________________ Address _____________________________________________________________________________ _______________________________________________________________Postcode _____________ Date of Birth _________________________________ Sex _____________________________________ I certify that this person is in good health to participate in full contact martial arts contests. Signed _____________________________________ Print Name _______________________________ Medical Practitioner Medical Practitioner Provider Number _____________________________ Date _______________________________________ Medical practitioner’s stamp 12 PART TWO – Medical and Competition History Division 1 – Personal Details and Competition History (To be completed by the contestant) Name of Sanda Contestant _________________________________________ Examination Date________________ Contestant’s address ______________________________________________ Date of birth ____________________ Contestant’s telephone number ______________________________________ Sex......M / F (circle one) 1. Career competition history: Career Results Wins Losses Draws Amateur Professional 2. Have you suffered any injury while competing? Yes / No (circle one) 3. Have you had any headaches, vomiting or problems with speech or vision after a contest? Yes / No (circle one) Division 2 – Medical History (To be completed by the medical practitioner) Y e s 1. 2. 3. 4. 5. Have you at present any: a. illness b. disability Are you now receiving medicine, drugs, or other treatment 10. a. Shortness of breath Has an accident or illness kept you off work for more than one week Have you ever had any operations Have you ever been a patient in any hospital: a. Medical b. Other 12. a. Coughing blood Have you ever had or are you now suffering from any of the following? 6. a. Rheumatic fever b. Heart disease 7. Palpitations or pounding heart 8. High or low blood pressure 9. Y e s N o Swollen or painful joints (other than through injury) 11. a. Pneumonia b. Bronchitis or pleurisy Y e s N o 20. a. Nervous trouble b. Severe depression c. Mental illness d. Attempted suicide 21. a. Kidney disease b. Bladder disease c. Pain passing urine d. Blood in your urine 22. Frequent indigestion b. Coughing up phlegm 13. Tuberculosis 23. a. Ulcer of stomach 14. a. Asthma 24. a. Gall bladder trouble b. Ulcer of duodenum b. Other lung disease 15. a. Deafness b. Tinnitus 16. a. Visual problems b. Do you wear glasses or contact lens 17. a. Fainting attacks b. Blackouts 18. a. Fits or convulsions b. Epilepsy c. Giddiness 19. a. Severe headaches b. Migraines 13 b. Gall stones 25. Sugar diabetes 26. a. Hepatitis or other jaundice b. Liver disease 27. a. Rupture b. Hernia c. Swollen or painful testicles 28. a. Any skin trouble b. Tendency to bruise or bleed easily 29. a. Concussion b. Severe head injury c. Loss of consciousness N o Y e s 30. Knee injury Y e s N o 32. Paralysis (including Ankle injury Back injury Other joint injury or dislocation 31. Fractured bones Chipped bones Y e s N o N o 34. (Females) polio) Are you pregnant? 33. Any other injury, illness or disability Medical Practitioner’s Notes on History (A ‘Yes” answer to any question requires the medical practitioner to state the question number and comment here) _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ 35. Over the past five (5) years has the contestant, either occasionally or regularly, taken any stimulants, sedatives, medications or drugs by mouth or by injection? Yes / No (circle one) If ‘Yes”, provide details and, if prescribed by a doctor, include the relevant particulars in question 36 below. 36. Over the past five (5) years has the contestant had any medical examination, advice, treatment or been in hospital? Yes / No (circle one) If ‘Yes”, provide particulars of each instance (including x-ray, electrocardiogram or other special tests) in the table below. Date Name and address of doctor and/or hospital Reason (If illness or injury, give duration and date of recovery) 37. Details of photographic identification presented to the medical practitioner, eg driver’s licence or passport: _____________________________________________________________________________________________ Contestant’s Declaration and Release of Medical Information Authorisation I declare that the information in the Certificate of Fitness true and complete to the best of my knowledge and belief. Contestant’s name (print) _________________________Signature______________________ Date _____________ I have completed the above medical history and have witnessed the contestant’s signature. Signature of medical practitioner _________________________________ Date ___________________________ Print Name ___________________________________________ THIS MEDICAL FORM AND THE INFORMATION HEREIN IS TO REMAIN CONFIDENTIAL AND SECURELY STORED BY THE PROMOTER FOR A PERIOD OF 12 MONTHS FROM THE DATE OF SIGNING. 14 PART THREE – Record of Medical Examination Medical Examination (Medical practitioner to complete) Tick the appropriate column. If not examined, insert ‘NE’ in the Normal column Physical Examination 1. Normal Abnormal Physical Examination a. Head, face, scalp b. Neck R.O.M. a. Nose deformity b. Nose airway a. Mouth, throat b. Speech a. Teeth, gums b. Dentures Yes / No 15.. 5. a. Ears – general b. Ears - hearing 19. 6. Tympanic membranes 20. 7. Eustachian tubes 21. 8. Eyes – general 22. 9. a. Visual fields b. Eye gaze 10. Normal 16. Abdomen (include hernial orifices) Endocrine system 17. External genitalia 18. 23. a. Feet b. Limbs R.O.M. c. Gait A. Spine b. Trunk R.O.M. c. Posture (standing) a. Nervous system b. Cranial nerves a. Cerebellum function b. Body balance/ coordination a. Muscle tone b. Muscle strength c. Sensation Reflexes Eye movement 24. Skin 11. Ophthalmoscopic examination 25. Lymphatic system Lymph glands in neck axillae or inguinal 12. Chest, lungs 26. Emotional stability 13. Heart (if ECH performed, note result in section & enclose F MED 53) Vascular system (include veins) 27. Other 28. Identifying marks 30. Height: (cm) 2. 3. 4. 14. 29. Frame: 31. Chest: (cm) Exp Ins 32. Waist (cm) 33. Urinalysis: Albumin Sugar 34. Weight: (kg) 35. Blood Pressure: Systolic 36. Eyes – colour 37. Distant vision: R6 Near vision: 38 Large Medium Small Diastolic Corr 6 L6 Abnormal to 6 Normal / Abnormal Has a MRI Scan been conducted? Yes / No Is the MRI satisfactory Yes / No Any further testing required? Yes / No Please attach a copy of the radiologist’s report. 39. Medical Practitioner’s Notes on Medical Examination (provide details of any abnormality noted and enter the relevant question number before each comment) _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ 40. Is any further testing required? Yes / No (circle one) 15 Neuro/Psychological Examination Yes 41. Is there any evidence of a change in character? 42. Has the contestant a good memory for recent events and, in particular, recent contests? 43. Does the contestant follow conversation with attention and intelligence? 44. Is there any evidence of a tendency to violence outside the competitive arena? No 45. Medical Practitioner’s Notes on Neuro/Psychological Examination (state whether further assessment is required) _____________________________________________________________________________________________ _____________________________________________________________________________________________ 46. Particulars of any Disabilities _____________________________________________________________________________________________ _____________________________________________________________________________________________ 47. Medical Practitioner’s Summary Name of examined contestant______________________________________________________________________ Do you consider the contestant to be in good health to participate as a contestant in full contact martial arts contests? Yes No Further Assessment Required (circle one) Any comments: _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Signature of medical practitioner_______________________________________________ Date ________________ Name of medical practitioner (please print)________________________________ Telephone number ____________ Address of practice ______________________________________________________________________________ THIS MEDICAL FORM AND THE INFORMATION HEREIN IS TO REMAIN CONFIDENTIAL AND SECURELY STORED BY THE PROMOTER FOR A PERIOD OF 12 MONTHS FROM THE DATE OF SIGNING. 16 Serology Report (Sanda Full Contact) Medical Practitioners Report I certify that: Name of Sanda contestant __________________________________________________________ Address of Sanda contestant ________________________________________________________ _______________________________________________________________________________ Attended for tests for H.I.V., Hepatitis B Antigen and Hepatitis C on ______________________________ (insert date) The test results: i. H.I.V. Negative ii. Hepatitis B Antigen Negative or immune iii. Hepatitis C Negative Other_________________________________________ Other____________________________ Other_________________________________________ Comment on results not negative or immune ____________________________________________________________________________________ ____________________________________________________________________________________ Medical Practitioners Signature _________________________________________________________ Date ________________________ Please Print: Name of medical practitioner ______________________________Telephone No.___________________ Practice Address_______________________________________________________________________ ____________________________________________________________________________________ THIS MEDICAL FORM AND THE INFORMATION HEREIN IS TO REMAIN CONFIDENTIAL AND SECURELY STORED BY THE PROMOTER FOR A PERIOD OF 12 MONTHS FROM THE DATE OF SIGNING. 17 APPLICATION INDEMNIFICATION WAIVER FORM TO PARTICIPATE IN THE 2015 AUSTRALIAN KUNG-FU WUSHU CHAMPIONSHIPS rd 3 May 2015 Ryde Community and Sports Center PARTICIPATING IN A MARTIAL ARTS TOURNAMENT IS DANGEROUS AND CAN CAUSE SERIOUS INJURIES ___________________________________________________________________________ 1. COMPETITIOR'S DETAILS: Given Names: ……………………………………………………….…………………... Last Name: ……………………………………………………………………………. Date of Birth: .……...........…... Address: ……………………………………………………………….………………... State: ……...................Postcode: ....................... Country: …………………………….. Ph (home).......................................Ph (work)…………………....………………... Mobile / Phone: ………………………………………………………………………… Email: …………………………………………………………………………………. 2. WAIVER AND INDEMNITY Applicant for him/herself, his/her executors, administrators, dependents and other personal representatives, hereby absolves and indemnifies the providers and all their servants, agents, employees and other students or persons under the providers control (the "indemnified") from all liability howsoever arising for injury or damage (including but not limited to the Applicants' person, whether fatal or otherwise, property and personal belongings) however caused including by the negligence of the indemnified, arising out of or participating in Martial Arts competition or in connection with Martial Arts or in any way caused by, or arising out of, any activity carried on by the indemnified. I, the Applicant, have been advised and understand that the practice of martial arts is potentially dangerous. I, the Applicant, agree to occupy and use the premises of the Kung Fu Wushu Australia Ltd (KWA) / Kung Fu Wushu NSW (KWNSW) at risk to myself and release to full extent permitted by law The KWA / KWNSW, and its agents, servants, contractors and employees from all claims and demands of every kind in of or resulting from any accident or damage to property or injury or death to myself while participating in a martial arts competition/event/contest conducted by the KWA / KWNSW. 3. MEDICAL DECLARATION I certify and acknowledge that I have NO physical disabilities or injuries that would impair my participation in any such competition or tournament and that I further certify that I do not suffer from any illness or blood related virus that may be transmitted to any other competitor, official or spectator. I declare that I have not been rendered semi or fully unconscious within the past four weeks from today’ date, and if prior to the event that I am rendered semi or fully unconscious I will notify the organiser and withdraw my registration. 4. MEDICAL TREATMENT I consent to any emergency treatment that may be necessary as a result of any injury that I may sustain during the course of the tournament. I fully understand that any medical treatment provided to me as a response to injury, will be of FIRST AID type only and I am duly reasonable to arrange any transport at my own expense to a suitable medical centre or hospital if it is deemed the injury requires further treatment or in the event I have been rendered unconscious 18 or unable I authorise for an ambulance to be called on my behalf to transport me to such a facility. 5. MARTIAL ARTS DONE AT APPLICANT'S OWN RISK Any person participating at any martial arts contest/event/competition organised by the KWA / KWNSW are only allowed to do so on the distinct understanding that they do so entirely at their own risk. 6. ACCEPTANCE OF COMPETITION SURFACE I accept that the competition surface will not be of the same type and construction as those used in International events. 7. PERSONAL PROPERTY I accept that the neither the KWA / KWNSW nor its agents or employees shall be responsible for any loss or damage to such personal property or equipment that I may bring to the competition/event/contest. 8. USE OF IMAGE I hereby grant my consent for any photographic or video recording of my performance to be used by the KWA / KWNSW or any entity that the KWA / KWNSW so authorises. I agree that I will make waive entitlement to any payment or compensation for the use of my image and/or performance. 9. RULES AND REGULATIONS I hereby acknowledge that my Instructor/Coach has explained in full the rules of the competition and I undertake to abide by the rules, regulations and resolutions of the competition organisers as they may decide during the course of the competition. 10. STATEMENT OF UNDERSTANDING I, the Applicant have read, or have had read to me the above conditions and having understood the same, I consent to the activities proposed. Signed (Applicant) ..................................................................................... Date .................................. [This application must be signed by a guardian if the Applicant is under the age of 18.] in the presence of (signature of witness) Name: ....................................................... Signed................................... Date ............................... SCHEDULE 1 In addition to the Kung Fu Wushu NSW Inc and Kung Fu Wushu Australia Limited., the providers in respect of this agreement include: (a) All State and territory branches of the KWA (b) All KWA staff, officials and volunteers, including but not limited to: Walt Missingham David Crook Frederic Ong (c) All KWNSW staff, officials and volunteers, including but not limited to: Alice Dong William Chow 19
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