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