Athlete Registration Athlete Registration If you are human, leave this field blank. YOU MUST BE PART OF A MUAYTHAI AUSTRALIA REGISTERED CLUB TO COMPETE ON MTA SANCTIONED EVENTS. Please check with your trainer or see if your club is listed here. If your club is not listed your trainer must register your club here First Name * Last Name * Postal Address * Postal Address Postal Address Postal Address City City State/Province State/Province Zip/Postal Zip/Postal REGION * SOUTH QLD (Below Mackay) NORTH QLD (Mackay & up) Gender * Male Female Date of Birth * Your Email * Your Mobile Phone * Name of your Coach * Coach/Trainers Phone * Gym Name * Location of Gym * QLD NSW NT ACT VIC TAS SA NT OTHER Have you practiced other Martial Arts Before? * Yes No Which other styles have you practiced & for how many years/to what level? * Fight Weight * WINS * WINS LOSSES * LOSS DRAWS * DRAW KO's * KO/TKO'S Class * -select- Amateur Pro Note: once you register as a PRO you can no longer fight as an amateur. i.e Pro's can only fight 5x3 Full Thai Rules Unpadded Junior Development Day * YES enter me into the GOLD COAST event October 26, 2019 NO I do not wish to enter this event JUNIOR DEVELOPMENT DAY REGISTRATION October 26 - Gold Coast Development Day Options. I would like to participate in Sparring only Scored Bout Either of the above Please choose if you'd like to participate in the development day for sparring only or for both sparring & a scored bout. Muaythai Australia DO NOT condone weight cutting of any form. Development Days are SAME DAY WEIGH IN as the competition day. You MUST register in the weight category which is your walk around weight. 8-9yrs Choose Weight Division 22-24kg 24-26kg 26-28kg 28-30kg 30-32kg 32-34kg 34-36kg 36-38kg 38–40kg 40-42kg 42–44kg 44-46kg 46-48kg Please select weight division for Development Day 10-11yrs Choose Weight Division 28-30kg 30-32kg 32-34kg 34-36kg 36-38kg 38–40kg 40–42kg 42-44kg 44-46kg 46-48kg 48-50kg 50-52kg 52-54kg 54–56kg 56–58kg 58-60kg 60-63.5kg 63.5-67kg 67+kg Please select weight division for Development Day 12-13yrs Choose Weight Division 30-32kg 32-34kg 34-36kg 36-38kg 38–40kg 40–42kg 42-44kg 44-46kg 46-48kg 48-50kg 50-52kg 52-54kg 54–56kg 56–58kg 58-60kg 60-63.5kg 63.5-67kg 67-70kg 70-73kg 73+kg 14-15yrs Choose Weight Division 48-50kg 50-52kg 52-54kg 54–56kg 56–58kg 58-60kg 60-63.5kg 63.5-67kg 67-70kg 70-73kg 73-76kg 76-79kg 79-82kg 82+ 16-17yrs Choose Weight Division 42-45kg 45-48kg 48-51kg 51-54kg 54-57 57-60kg 60-63.5kg 63.5-67kg 67-70kg 70-73kg 73-76kg 76-79kg 79-82kg 82-85kg 85-88kg 88-91kg 91-95kg 95+kg Medicare Number * Do you suffer from any of the following medical conditions? If yes please tick & give further details below * NO MEDICAL CONDITIONS HAEMOPHILIA HEPATITIS HEART DISORDER EPILEPSY DIABETES RESPIRATORY NERVOUS SYSTEM DISORDER PSYCHOLOGICAL DISORDER BLOOD DISORDER HIV/AIDS OtherOther If you have current bloods / medicals please upload them below, if you do not have them at this time you can log in and add them later. Blood Serology Results (16yrs+ only) - Valid within 12 months Drop a file here or click to upload Choose File Maximum upload size: 134.22MB HEP B, HEP C & HIV Medical Form - Valid within 12 months Drop a file here or click to upload Choose File Maximum upload size: 134.22MB download new medical form here Applicant Declaration * I confirm that my instructor has explained to me the training methods used in the art of Muaythai. I accept that the practice of martial arts involves the risk of injury. I agree to abide by the rules set by Muaythai Queensland Inc SIGNATURE OF APPLICANT * Clear use your mouse, finger or touch pen to sign your name or draw your signature Parent / Guardian Declaration * I confirm that I consent to the above application & that I have been informed of the nature of & potential risk of martial arts training by the gym instructor Parent / Guardian Name * PARENT / GUARDIAN SIGNATURE * Clear use your mouse, finger or touch pen to sign your name or draw your signature Your annual membership fee for Muaythai Queensland inc is $30.00 and is to be paid in full on application/renewal date. Your passport will be mailed to the address written on this form. Credit Card Number * Enter your payment details. The $30.00 registration fee will be deducted from your account Yes our site is secured by https. Your payment details are not retained or stored by Muaythai Queensland Inc. Payment details are processed securely via our PCI Compliant payment gateway - Stripe. You may view Stripes privacy terms here and security here Register
