Canadian Karate Association

Association Canadienne de Karate

Black Belt Application (Insurance)

Name (First and Last):________________________Sex: M / F	Age:______ Birthdate:_____________

Address:_______________________________________________ Postal Code:____________

Phone:_______________ Email:__________________________________________________

DOJO: _______________________________City: _________________Province: __________

Chief Instructor: ________________________________Level:___________________________

Date of your grading:

SHODAN:	GODAN:
NIDAN:	ROKUDAN:
SANDAN:	SHICHIDAN:
YODAN:

Medical Information	Yes	No
1.	SENSES DISORDER:
A.	Do you suffer any visual disorder?
B.	Do you wear glasses?
C.	Do you wear contact lenses?
D.	Do you have any hearing problems?
2.	NERVOUS SYSTEM DISORDER
A.	Do you have any fainting problems?
B.	Do you suffer from epilepsy?
C.	Did you ever have a cranial trauma?
D.	Do you suffer from any cervical or neurological disorder, other than those mentioned above?
3.	BREATHING DISORDER
A.	Do you suffer asthma or any other breathing disorder?
4.	KIDNEY DISORDER
A.	Did you suffer or are you suffering from any kidney disorder?
5.	MUSCLE AND SKELETAL DISORDER
A.	Do you have any movement limitation from one of your limbs, back or spinal cord?
B.	Do you suffer any muscle weakness?
6.	SYSTEM DISORDER
A.	Do you suffer from Diabetes?
7.	SKIN DISORDER
A.	Do you suffer from any contagious skin disorder?
8.	CARDIO VASCULAR DISORDER
A.	Do you suffer from any cardiac or vascular disorder?
9.	OTHER CONDITIONS
A.	Do you take any medication?
B.	Have you received any surgical intervention lately?
C.	Do you suffer from any illness or infection other than those mentioned above?

_____________________________________________	____________________________

Signature and Date (Parent Signature if younger than 16)	Chief Instructor Signature and Date