Medical Declaration For Ifma Athletes (Page 2 of 3) in pdf

Medical Declaration For Ifma Athletes Page 2

MEDICAL DECLARATION FOR IFMA ATHLETES

MEDICAL HISTORY STATEMENT

I have completed this medical history questionnaire and answered it truthfully and to the best of my knowledge. I am prepared to

answer questions from the International Federation of Muaythai Amateur (including athletic trainers, nurses, consultants, coaches, and

coordinators) and general practitioners concerning this medical history and medical conditions. I affirm also that I do not suffer from

any disability, injury, condition, or complaint that I have not disclosed on this form. I further recognize the importance of fully and

accurately disclosing my physical conditions, past and present, to International Federation of Muaythai Amateur.

________________________________________________

_____/______/_______

ATHLETE SIGNATURE

DATE

*To be signed by parent/guardian if the participant is under 18 years of age.

Name of Parent/Guardian: _________________________________________________________________________________

________________________________________________

_____/______/_______

PARENT/GUARDIAN SIGNATURE

DATE

MEDICAL DOCTOR EXAMINATION & APPROVAL:

The applicant’s medical fitness for the contact ring sport of Muaythai has been evaluated by physical examination and, if required (at

the discretion of the attending physician) by the use of radiology and laboratory facilities.

This is to certify that ………………………………………………………………………………is in good physical condition and not suffering from any injury,

infection or disability liable to affect his capacity to box in the competitions of the full contact sport of Muaythai.

________________________________________________

_____/______/________

PHYSICIAN SIGNATURE

DATE

CLINIC ADDRESS: ___________________________________________________________________________________________

TEL: ________________________________________________EMAIL: ________________________________________________

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Medical Declaration For Ifma Athletes Page 2