RKA Affiliate Application - Powered by Keap

ROUFUSPORT KICKBOXING ASSOCIATION
Application for Affiliate Membership

AN AFFILIATE MEMBER MUST BE THE OWNER OR HEAD INSTRUCTOR OF A SCHOOL

School Name *

*Owner/Chief Instructor's First Name
*Owner/Chief Instructor's Last Name

Title

Date of Birth *

**The "Affiliate" membership rests with this individual. Should this person retire or otherwise leave the school the RKA Affiliation will become null and void until and when the new owner/head instructor applies for a new RKA Affiliate Membership.

School Phone Number *

Mobile Number *

Owner/Chief Instructor Email *

Street Address 1 *
Street Address 2
City *
State *
Postal Code *
Zip +Four
Country *

Website

Principal Martial Arts Style *

Current Rank *

Your Instructor's Name *

Your Instructor's Rank *

Briefly explain your goals in affiliating with RKA *

If "Other" Please Explain

What year, where and with whom did you first start your Martial Arts training *

List your EARNED black belt ranks, date earned, certifying organization and instructor *

List your top six tournament and/or competition wins, event names and dates *

List your teaching positions (starting with the current one), dates, school name(s) and location(s) *

How many students have you personally promoted to black belt, if applicable

Any significant accomplishments by one or more of them, if applicable

List any other special accomplishments or awards that you feel are appropriate

I understand that you will check my background and thereby I assert that this information is true and accurate.

If approved, I agree to abide by all of the rules and regulations of the Roufusport Kickboxing Association (RKA). I understand that violation of any rules of the Association standards or requirements may result in revocation of my affiliation, as well as, mine and my student's RKA certified rank. I furthermore understand that RKA does not accept responsibility and/or liability for any action, in any manner, undertaken by an affiliate, associate or their agent.

I AGREE *

Electronic Signature-Please type name *

Date *

Thank you for your interest in becoming a certified Roufusport Kickboxing Association Affiliate Owner. Your application and credentials will be reviewed by Duke Roufus. If approved, you will be contacted by an RKA Representative who will answer any questions you may have, as well as, guide you through the final steps of the enrollment and certification process, if applicable.