MEMBERSHIP APPLICATION Office Use Only - Assigned Membership #_______

Must be printed, filled out and sent via mail  Use the print icon in the upper left-hand corner to print 

Do Not complete this form If You have a current membership Card All Participants must be registered Prior to weigh in and medical evaluation This form is for NEW MEMBERS ONLY MAIL TO:

                               KICK International, 101W. Argonne Ave Ste11 , St. Louis, MO, 63122, USA                  

    DATE ______                           no personal checks accepted

THIS APPLICATION MUST BE READABLE OR YOU WILL NOT RECEIVE YOUR PERMANENT MEMBERSHIP CARD

First Name: _________________    MI:____  Last Name: ________________________

Phone Number: _(    )____________        Email Address: ________________________

Street Address: __________________________     City: ________________________

State: __________ Zip Code: __________ 

Trainer's Name __________________, Street Address ________________________

City ____________State______ Zip_________ Telephone __________________

Birthdate: (example: 7/22/1982)  _______ Sex (circle one): Female Male

Mark your request for registration MMA_______ Kickboxing _________

Judge___ Referee__ Trainer__ Corner____ Doctor(N/C)____ COMPETITOR______

If you wish to participate as a competitor please provide the following

Weight: (whole lbs.) _______ Height: (feet, inches) __________

Have you ever competed in any other kickboxing or MMA competition in the past?

If so provide information as to how many times and if you won or lost.

Other organizations you have competed for___________________________

KICKBOXING RECORD WINS___ LOSS____ DRAWS___Knockouts ___

MMA RECORD WINS____LOSS___ DRAWS______ Knockouts _____

Before we can process your application you must- Acknowledge and sign the following form

                             This is a Membership Release and Waiver, READ BEFORE SIGNING

IN CONSIDERATION OF MEMBERSHIP GRANTED ME OR MY SON/DAUGHTER BY KICK INTERNATIONAL. (KICK INTERNATIONAL) TO PARTICIPATE AS AN AMATEUR IN ANY MARTIAL ARTS APPROVED OR SANCTIONED EVENTS INCLUDING KICKBOXING OR MIXED MARTIAL ARTS OF ANY KIND, DURING MY OR HIS/HER TENURE. I, THE UNDERSIGNED, TAKE THE FOLLOWING ACTION FOR MYSELF, MY HEIRS, NEXT OF KIN, EXECUTORS, ADMINISTRATORS, SUCCESSORS MY PERSONAL REPRESENTATIVE AND ASSIGNS: I agree that: A) I WAIVE, RELEASE, AND DISCHARGE FROM ANY AND ALL CLAIMS OR LIABILITIES FOR DEATH OR PERSONAL INJURY OR DAMAGES OF ANY KIND, EXCEPT THAT WHICH IS THE RESULT OF GROSS NEGLIGENCE AND/OR WANTON MISCONDUCT OF PERSONS OR ENTITIES LISTED BELOW, WHICH ARISE OUT OF OR RELATED TO MY PARTICIPATION IN, OR MY TRAVELING TO AND FROM AMARTIAL ARTS EVENT, MMA, OR KICKBOXING EVENT OR SUPERVISED PRACTICE. THE FOLLOWING PERSONS OR ENTITIES: KICK INTERNATIONAL AND ITS RECOGNIZED CERTIFIED CLUB; EVENT FACILITIES; THE TOURNAMENT DIRECTORS; SPONSORS; OFFICIALS; COACHES; EVENT PHYSICIANS AND THE OFFICERS, DIRECTORS, EMPLOYEES, REPRESENTATIVES, AND EMPLOYEES, REPRESENTITIVES AND AGENTS OF ANY THE ABOVE;B) I AGREE NOT TO SUE ANY OF THE PERSONS OR ENTITIES MENTIONED ABOVE FOR ANY OF THE CLAIMS OR LIABILITIES THAT I HAVE WAIVED, RELEASED OR DISCHARGED HERIN; AND C) I INDEMINIFY AND HOLD HARMLESS THE PERSONS OR ENTITIES MENTIONED ABOVE FROM ANY CLAIMS MADE OR LIABILITIES ASSESSED DURING MY PRESENCE OR PARTICIPATION. I WILL REMOVE MYSELF FROM PARTICIPATION AND BRING SUCH TO THE ATTENTION OF THE NEAREST OFFICIAL IMMEDIATELY.D) I UNDERSTAND AND AGREE THAT ALL KICK INTERNATIONAL MEMBERS AND AFFILIATED MEMBERS, OFFICIALS, PARTICIPANTS AND THEIR GUESTS PARTICIPATE VOLUNTARILY AND AT THEIR OWN RISK IN ALL KICK INTERNATIONAL ACTIVITIES. E) I, THE UNDERSIGNED, FULLY UNDERSTAND THAT PARTICIPATION IN THE SPORT OF KIICKBOXING/MMA CARRIES A RISK TO ME OF SERIOUS INJURY INCLUDING PERMANENT PARALYSIS OR DEATH. I VOLUNTARILY AND KNOWINGLY WILL ABIDE BY ALL RULES, REGULATIONS AND DECISIONS OF KICK INTERNATIONAL AND RECOGNIZE, ACCEPT AND PERSONALLY ASSUME ANY AND ALL RISK. I ACKNOWLEDGE THAT I AM COMPETING AS AN AMATEUR AND CAN NOT AND WILL NOT ACCEDPT ANY PAYMENT WHICH CAN BE RECOGNIZED AS A FEE OR PURSE TO COMPETE. IF I AM PAID TO COMPETE I ACKNOWLEDGE THAT I WILL NOT BE COVERED BY INSURANCE PROVIDED BY KICK INTERNATIONAL AND SHALL FROM THIS POINT FORWARD BE NO LONGER BE CONSIDERED AS AN AMATEUR.

For good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, I hereby authorize KICK and its designee, if any, to use my name and likeness and to record by any audio and/or visual electronic means any sanctioned event(s) in which I appear. This waiver is effective in perpetuity and authorizes the use of my name and likeness and the recording(s), if any, of KICK sanctioned events throughout the world for broadcast and re-broadcast by KICK or its designee , with out any additional compensation to me.) WAIVER OF RIGHTS UNDER STATE STATUTE

I further agree to waive all benefits flowing from any state statute which would negate or limit the scope of this Release and Indemnification Agreement including, but not limited to, Section 1542 of the California Civil Code which provides: "A general release does not extend to the claims which a creditor does not know or suspect to exist in his favor at the time of executing the release, which if known to him must have materially affected his settlement with the debtor"

ALL PARTICIPANTS: I CERTIFY THAT I HAVE HAD NO INJURIES TO MY HANDS, FEET, OR LEGS, NEITHER FRACTURES NOR BROKEN BONES, WHICH EXIST OR OCCURED WITHIN THREE MONTHS PRECEDING THE DATE OF THE ATHLETE MEMBERSHIP APPLICATION FORM, AND KNOW OF NO INJURIES TO THE HEAD, CONCUSSION OR FAINTING SPELLS, I WILL NOTIFY MY COACH, TRAINER, OR OTHER LOCAL KICKBOXING OFFICALS IMMEDIATELY SHOULD ANY OF THESE INJURIES OR CONDITIONS BE EXPERIENCED IN THE FUTURE. I FUTHER AGREE THAT IF I DO EXPERIENCE ANY IF THE AFOREMENTIONED CONDITIONS OR INJURIES. I WILL IMMEDIATELY CEASE TRAINING, SPARRING AND COMPETING AS A KICKBOXER UNITL SUCH CONDITIONS OR INJURIES NO LONGER EXIST.

FEMALE PARTICIPANTS ONLY: I CERTIFY THAT I AM NOT PREGNANT, OR HAVE ANY PAINFUL PELVIC DISCOMFORT SUCH AS SYMPTOMIC ENDOMETRIOSIS OR OTHER CAUSES, ABNORMAL VAGINAL BLEEDING OF UNDETERMINED CAUSES (ETIOLOGY), RECENT LOSS OF MENSTRUAL PERIOD (SECONDARY AMENORRHEA), RECENT DEVELPOMENT BREAST MASS, RECENT BREAST DYFUNCTION PREVIOUSLY NOT PRESENT OR SURGICAL BREAST IMPLANTS, AND UNDERSTAND THE KICK INTERNATIONAL OFFICIAL RULES AND REGULATIONS PERTAINING TO MY PHYSICAL CONDITION. I FURTHER AGREE THAT I WILL IMMDEIATELY NOTIFY MY COACH, TRAINER, OR OTHER LOCAL KIICKBOXING/MMA OFFICIAL IF ANY OF THE ABOVE DESCRIBED CONDITIONS SHOULD DEVELOP/APPLY.

By signing this release I certify that: I, the undersigned, have read this Release/Waiver and understand all its terms and conditions. I execute it voluntarily and with full knowledge of its significance.

Signed_________________________________Date_____/_____/_____

(Participant's Full Name)

PARENTAL WAIVER: I, the undersigned, ____________________________ (parent/guardian) the parent and natural guardian of ___________________________ (minor's name) hereby execute the foregoing Waiver and Release for and on behalf of the minor named herein. I hereby bind myself, the minor and all other assigns to the terms of the waiver and release. I represent that I have legal capacity and authority to act for and on behalf of the minor name herein, and I agree to indemnify and hold harmless the persons or entities mentioned above for any claims or liabilities assessed against them as a result of any insufficiency of my legal capacity or authority to act for and on behalf of the minor in the execution of the Waiver and Release.

*Signed___________________________________ Date_____/_____/_____

*REQUIRED IF ATHLETE IS A MINOR (Parent(s) or Legal Guardian

Athlete/Non-Athlete Code of Conduct

Outlined below is the KICK INTERNATIONAL, INCLUDING MARTIAL ARTS UNDER JURIDICTION OF SANCTIONING BODY / WAKO Code of Conduct. I understand that my compliance with the Code is a requirement for my participation in KICK INTERNATIONAL, INCLUDING MARTIAL ARTS UNDER JURIDICTION OF SANCTIONING BODY / WAKO events. I also recognize that this Code does not establish a complete set of rules that prescribes every aspect of appropriate behavior.

Further, I:

1. Will act in a manner consistent with the spirit of fair play and responsible conduct;

2. Will recognize, respect and adhere to the authority of KICK INTERNATIONAL, INCLUDING MARTIAL ARTS UNDER JURIDICTION OF SANCTIONING BODY / WAKO appointed coaches and team leaders;

3. Will attend all team functions, to include meetings, practices, press conferences, competitions, etc. unless excused or otherwise instructed by the team leader or KICK INTERNATIONAL, INCLUDING MARTIAL ARTS UNDER JURIDICTION OF SANCTIONING BODY / WAKO designee;

4. Will comply with KICK INTERNATIONAL, INCLUDING MARTIAL ARTS UNDER JURIDICTION OF SANCTIONING BODY / WAKO, uniform requirements;

5. Will be within 5 pounds of my competition weight;

6. Will adhere to all curfews established by the team leader or KICK INTERNATIONAL, INCLUDING MARTIAL ARTS UNDER JURIDICTION OF SANCTIONING BODY / WAKO designee;

7. Will maintain an appropriate level of fitness to promote optimal athletic performance;

8. Will make every effort to perform to the best of my abilities;

9. Will refrain from the use of performance-limiting drugs, including, but not limited to, tobacco and alcohol;

10. Will refrain from using any substance on the Anti-Doping Code or KICK INTERNATIONAL, INCLUDING MARTIAL ARTS UNDER JURIDICTION OF SANCTIONING BODY / WAKO, banned substance list, as enforced by WADA and USADA, and will abide by the drug testing procedures of USADA, and WADA.

11. Will abide by the policies and rules established by KICK INTERNATIONAL , INCLUDING MARTIAL ARTS UNDER JURIDICTION OF SANCTIONING BODY / WAKO,;

12. Will respect others, including my teammates, coaches, competitors, officials and spectators;

13. Will not engage in, nor tolerate, any form of verbal, physical or sexual abuse;

14. Will respect the property of others;

15. Will refrain from profanity and derogatory language that would reflect negatively on me and KICK INTERNATIONAL, INCLUDING MARTIAL ARTS UNDER JURIDICTION OF SANCTIONING BODY / WAKO;

16. Will refrain from illegal or inappropriate behavior that would detract from a positive image of me and KICK INTERNATIONAL, INCLUDING MARTIAL ARTS UNDER JURIDICTION OF SANCTIONING BODY / WAKO;

17. Will refrain from engaging in any behavior that could detract from my ability, or my teammates' ability, to perform optimally;

18. Will maintain a positive attitude and act in a way that will bring honor to me, the team, KICK INTERNATIONAL, INCLUDING MARTIAL ARTS UNDER JURIDICTION OF SANCTIONING BODY / WAKO and the United States of America;

19. Will limit socialization with members of the opposite sex to public areas, exceptions being immediate family members, members of the KICK INTERNATIONAL, INCLUDING MARTIAL ARTS UNDER JURIDICTION OF SANCTIONING BODY / WAKO delegation and/or other times as approved by the team leader;

20. Will remember that I am an ambassador for KICK INTERNATIONAL, INCLUDING MARTIAL ARTS UNDER JURIDICTION OF SANCTIONING BODY / WAKO, my country and the WAKO movement. Any member present during any violation of the Code of Conduct should leave the area immediately or be considered a participant by choice.

Disciplinary Procedures and Penalties

Failure to comply with the Code of Conduct set forth in this document for KICK INTERNATIONAL, INCLUDING MARTIAL ARTS UNDER JURIDICTION OF SANCTIONING BODY / WAKO may result in disciplinary action in accordance with the penalties outlined in this agreement or in KICK INTERNATIONAL, INCLUDING MARTIAL ARTS UNDER JURIDICTION OF SANCTIONING BODY / WAKO Constitution and By-laws.

Penalties could include:

1. Immediate dismissal from team and return home at athlete's expense.

2. With-holding of a portion or all of any stipend(s) received from KICK INTERNATIONAL, INCLUDING MARTIAL ARTS UNDER JURIDICTION OF SANCTIONING BODY / WAKO, etc.

3. Suspension from KICK INTERNATIONAL, INCLUDING MARTIAL ARTS UNDER JURIDICTION OF SANCTIONING BODY / WAKO activities for a specified period.

Violations requiring immediate action will be handled in accordance with KICK INTERNATIONAL, INCLUDING MARTIAL ARTS UNDER JURIDICTION OF SANCTIONING BODY / WAKO Constitution and By-laws...

Any appeal taken for disciplinary action rendered in an emergency hearing shall be to KICK INTERNATIONAL, INCLUDING MARTIAL ARTS UNDER JURIDICTION OF SANCTIONING BODY / WAKO National Board of Review and will be conducted in accordance with KICK INTERNATIONAL, INCLUDING MARTIAL ARTS UNDER JURIDICTION OF SANCTIONING BODY / WAKO Constitution and By-laws.

Acceptance

I pledge to uphold the spirit of this Code, which offers a general guide to my conduct as a participant in a KICK INTERNATIONAL, INCLUDING MARTIAL ARTS UNDER JURIDICTION OF SANCTIONING BODY / WAKO event. I agree to follow the KICK INTERNATIONAL, INCLUDING MARTIAL ARTS UNDER JURIDICTION OF SANCTIONING BODY / WAKO Grievance Procedures if I am charged with violation of the Code. I have familiarized myself with the Code and understand that my acceptance of it, as signified by my signature below, is a condition of my membership in this KICK INTERNATIONAL, INCLUDING MARTIAL ARTS UNDER JURIDICTION OF SANCTIONING BODY / WAKO event.

Participant Name (Printed) __________________________ Date____________________

Participant Name (Signature) ________________________________________________

Guardian or parent ( Printed Name -If applicable)___________________Date________

Guardian or Parent (Signature -If Applicable )______________________________________

Witness ___________________________________

I as a parent or guardian shall agree and abide by such agreement if I am signing for an under age member

Guardian or parent required for anyone under the age of 18.

Page 2 of 2

To be completed prior to your first event and carried with you at ALL TIMES

ANNUAL PHYSICAL EXAMINATION DATE: ________________

CONTESTANT'S NAME:_______________________________

DATE OF BIRTH:____________________________________

FEDERAL/NATIONAL ID#__________________CURRENT WEIGHT ____ HEIGHT _________

EXAMINATION TO BE COMPLETED BY LICENSED PHYSICIAN (MD) ONLY:

UNLESS STATED Indicate normal findings by placing a check on each line

VISION must be at least 20/70 without corrective lenses

1. Visual Acuity: List Actual Peripheral Vision (DEGREES)

2. Pupils: Regular Equal React to light Anterior Segment

3. Periorbital Regions (describe scars, if any)

4. Oropharynx: Ears (discharge, etc.)

5. Lungs: (Any abnormal breath sounds, friction rub, rales, etc.)

6. Heart Rate: List Actual Irregularity Murmur

7. Pulse Rate: List Actual Blood Pressure: List Actual

8. Abdominal Exam:

9. Extremities (Stiffness, swelling, tenderness): YES NO

10. Hands (fists): Any Fractures or Swelling: YES NO

11. Nervous System: Orientation Cerebellum Cranial Nerves

12. Nose: Instability YES NO Obstruction YES NO

13. Coordination: Finger to Nose - Normal Abnormal

14. Tandem Gait: Normal Abnormal

15. History of any irregular symptoms

Yes No Yes No

Chest Pains unexplained Weakens

Shortness of Breath Unexplained Weight loss

Loss of consciousness Neck or back Pain

Duration of unconscionness Headaches

Fainting with /without exercise Unexplained Weakness

16. Physical Exam Results Normal

Yes No Yes No

Head Heart

Eyes Abdomen

Extremities Vision

Neck Lungs

Neurological Exam Skin

17. DOES THE PATIENT SPECIFICALLY SHOW ANY evidence of any of the following?

Yes/ No                      Yes/ No

Retinal injury/ detachment Cardiac Disease

Neurological deficit Respitory Disorder

Post concussive syndrome any loss of paired organs

Intracranial Aneurysm Cervical Disorder

Prescription medications drug allergies/supplements

Additional information or comments.

You must provide verification of blood testing as required for proof of:

Negative Hepatitis B and C (within six months)

Negative HIV (within six months)

EKG Results (within 1 year)

Would there be any other medical issue that would impair the athlete's ability to participate in competitive combative sports such as categorized as Kickboxing or Mixed Martial Arts?

15. Patient/ Athlete's responsibility to obtain and carry your annual medical assessment and proof of blood work to all events and to provide this information to the pre fight physical physician for review. It is your responsibility to retain this as your private and personal information.

16. Based upon the above information, physical exam and test results, this individual appears to be in good physical condition to compete in competitive combative sports categorized as Kickboxing or Mixed Martial Arts YES NO

IF NO, STATE REASON(S)

PHYSICIAN'S SIGNATURE: DATE:

NAME OF PHYSICIAN (PRINT):

Medical License # and State of issuance # ________________________________________________

TELEPHONE #:____________ FAX #:_________________

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