HEALTH DECLARATION FORM - Chia Laguna Half Marathon

3 MAY 2015
HEALTH DECLARATION FORM
Fill out completely and return - attached to registration form and signed by the physician - by
Fax : +39 041.5086461.
Email: chia@tds-live.com
PLEASE, USE BLOCK LETTERS ONLY :
I, Dr (first name and last name)
born in
on
with office at (complete address)
phone number
email address
declare myself fully responsible and being aware of the consequences of falsely declaring that
Mr/Mrs/Miss (first name and last name)
born in
on
resident in (complete address)
ID document ______________________________ number________________________________
based on a sport medical exam done my me on (dd/mm/yy)_______________________________
is in good health and physically fit to participate in a competitive half marathon according to
current laws in __________________ (country).
The certificate is valid 1 year from the date of issue.
Date
Physician’s signature
Personal history records are held in the head office of A.S.D. Laguna Running, Viale Belvedere, Chia – 09010 Domus de Maria (CA),
Italy and they may be reviewed, altered and cancelled at any time upon the individual’s request and addressed to the legal
representative responsible for the handling of said records.