Combat Sports Commission - New Registrant Form
Issued under the Combat Sports Act 1987
Applications will not be processed unless ALL required documentation is submitted and the appropriate fee paid. Additional documentation is to be emailed to combatsport@dlgsc.wa.gov.au.
Photo Identification and a head shot photo is required from all applicants. All except Contestants must submit a Statement of Experience. Contestants must submit a valid Certificate of Fitness and Serology Report.
Full Name
Street Number
Street Name
Street Type
Suburb
State
Post Code
Home Phone
Mobile Phone
Gender
Date of Birth
Gym / Trainer Name
Emergency Contact Person / Next of Kin:
Emergency Contact Name:
Emergency Contact Number:
Registration Capacity:
Additional documentation should be emailed to combatsport@dsr.wa.gov.au. All registrations are valid for 3 years from date of application.
Please select all that apply:
Officials: If you are registering as a Referee, Judge and Timekeeper the total fee owing is $101.50. If you are registering as a Judge and Timekeeper the total fee owing is $81.
Registration Class:
There is no additional cost for registering in more than one class.
Please select all that apply:
If other, please specify:
Previous Registration:
Have you ever been registered with any other Combat Sport Authority?
If so, which State/Country?
Class/Combat Sport:
Capacity
Identification Details:
Photo Identification must be provided to the Combat Sports Commission, via Em:combatsport@dsr.wa.gov.au or fax, post or in person
Indicate the type of identification you will provide
Place of Issue
Expiry Date
Contest Record (for contestants only):
Please indicate your Win-Loss-Draw record for each discipline
If you do not have a contest record please type Debut
Probity Check:
Have you ever been convicted at court, or are you currently charged with any criminal offence?
If yes, please provide details below:
Details:
DECLARATION:
Declaration - I declare that the information provided in this application is true and correct in every detail. I acknowledge under Section 53 of the Combat Sports Act 1987 I am liable for a fine of up to $12,000 if I provide any information that is false or misleading.
Probity Check
I acknowledge that I may be subject to a probity check to determine if I am a fit and proper person for registration under the Combat Sports Act 1987.
Permission to Disclose and Publish Personal Information
I give permission to the WA Combat Sports Commission to publish my personal registration details, contest records and medical details in the database of the Commission and I approve of the Commission disclosing such details to other regulatory bodies in Australia and elsewhere.
Agreement to Participate in Anti-Doping Testing
I agree to participate, when requested to do so, in anti-doping testing for substances and methods prohibited by the Australian Sports Anti-Doping Authority (ASADA) and the World Anti-Doping Agency (WADA) in the current WADA List of Prohibited Substances and Methods. I acknowledge that I must not take or allow any person to administer to me any substance or method that is listed as prohibited in the WADA List of Prohibited Substances and Methods.
Agreement to Complete Online Education Unit
I (and my parent or guardian for contestants under 18 years of age) agree to participate in and complete the Commission’s online education unit. I understand that completion of the module is a standard condition of registration.
By selecting Yes I acknowledge that I have read and understood the Declaration and bind myself to the conditions of the declaration.
Date
Parental Consent: This MUST be completed by the parent/guardian of the applicant where the applicant is under 18 years of age.
I, as parent / guardian of the applicant who is a minor, assert that I have the legal authority to act on behalf of the minor, and I execute the above Declaration on behalf of the minor, and bind myself and the minor to its conditions.
Name of Parent/Guardian
Relationship to Applicant
Date
CONDITIONS OF REGISTRATION
The Commission intends to impose on you, the standard conditions relevant to this application that are set out in the Commission’s Guidelines and Conditions for Combat Sports Registrants document available on the Commission’s website. If you consider that one or more standard conditions should not be imposed, you are entitled to make a submission.
Do you wish to make a submission?
If yes, please contact the Commission.
Please note that the Commission may form the intention, after considering your application, to impose additional or different conditions or restrictions. If that occurs, the Commission will inform you of that intention and provide an opportunity to make a submission on that matter before the Commission makes its decision.