Medical Certificate Example Cyclosportives

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MEDICAL FORM
CYCLOSPORTIVES
n° Ident GT:
Name :
First Name :
Sex (M/F) :
Date of birth :
/
/
Address :
Zip Code :
City :
Country :
Tel :
e-mail :
Please send the following certificate stamped and signed by your doctor :
I undersigned doctor :
Certify having examined Mr., Mrs., Miss :
And find him capable of participating in competitive
Date, stamp and signature are obligatory.
PARENTAL AUTHORISATION
(for any inscription of minor from 14 to 17 years)
I, the undersigned, Mr/Mrs/Miss/Ms……………………………………(name)
Of …………………………………………………………………..(address)
Authorise my son/daughter……………………………(name), …………… (M/F)
to participate in the cyclo-sportif organised by TOP CLUB and SPORT COMMUNICATION.
I have taken note that it is up to me to obtain, for my son/daughter, the accident/injury insurance
of my choice. (To this effect, I have filled in the registration form, including: licence, insurance,
and medical insurance).
In case of an accident, please inform…………………………………….(name)
………………………………………(telephone number).
I here by authorise that all the information contained here in is true.
Date and Signature.
Read and approved.

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