Transcript HEALTH FORM XX PALERMO MARATHON –16 NOVEMBER 2014

HEALTH FORM
XX PALERMO MARATHON –16 NOVEMBER 2014
Complete and return by fax to: 0039/(0)91/6193303;
or by email to: [email protected]; [email protected]
or by post to: Comitato Organizzatore Maratona Città di
Palermo – Via Faggio 73– 90044 – Carini- (Pa)
PLEASE USE BLOCK LETTERS ONLY
I, Dr. (name, surname) _____________________________________________
born (city, country) ______________________ on (dd/mm/yyyy)___________
with office at (complete address)
_____________________________________________________________
Phone number ____________________________________
declare myself fully responsible and acknowledge the consequences for falsely
declaring that Mr./Mrs. (name/surname)
_______________________________________________________________
born (city, country)________________________on (dd/mm/yyyy)_________
and resident at (complete address)
_______________________________________________________________
with the following disability (if applicable)
_______________________________________________________________
based on a sport physical exam done by me on (dd/mm/yyyy)_____________
is in good health and fit to compete in half marathon/ marathon according to current
laws.
This certificate is valid one year from this date
Date______
Doctor’s signature____________________