KA Event Insurance Certificate Request Form
Associated Documents:
Sanctioning Policy
Tatami Mat Rental Form
Sanctioning Request Form
Club Contact Information
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Club Information
Legal Club Name
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Event Information
Event Title
*
Event Category
*
Tournament
Training Clinic/Workshop
Coaching/Officiating Course
Other
Location of Event
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Event Start Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Event Finish Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Will event have liquor exposure?
*
No
Yes
Will the event include activities other than Karate?
*
No
Yes - if yes add note at end of submission
Estimated Number of Participants
*
Estimated Number of KA Members
*
Estimated Number of Non-KA Members
*
If the actual number exceeds estimate by 25% please update by email to president@karateab.org
Additional information
I understand that I will be invoiced @ $7.50/ Non-KA member participating at the event for Insurance
*
YES
Submit
Should be Empty: