DECLARATION of health XXXII Half Marathon Firenze

DECLARATION of health XXXII Half Marathon Firenze-Vivicittà
Fill out completely sign and return by fax to Lega Atletica Uisp Firenze number: +39 0559029629
or by email [email protected]
Please use block letters only
I, Dr.(first name, last name)_________________________________________________________
born (city) _________________________ prov. _________________________________________
Country______________________On (dd/mm/yyyy)_____________________________________
with office at (complete address)___________________________ Phone n°__________________
declare myself fully responsabile and acnkowledge the consequences for falsely declaring that
Mr/Mrs/Ms (first name, last name) ______________________________
born (city) _______________________ prov. ___________________ 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 a 21.097 metres half marathon according to the current laws.
This certificate is valid one year from this date.
Date ______________
Physician’s signature _________________________________