ISSRA AGE VERIFICATION & HEIGHT PREDICTION PROFORMA
Annexure 1
To be filled (PRINT) in by the Subject/Parent/Sports federation and to be verified by the ISSRA Rep
Computer Code:
Date:
PERSONAL DETAILS (To be filled in by the Subjects/Parents)
TOURNAMENT DETAILS(in case of players)
Name of
Full Name
Tournament
Date of Birth
Venue
Age at last
Dates
birthday
Country
Age Group
Home Address
Phone No.
E-mail
SECTION 1 ( Chronological age) - To be filled in by the Subject/Parents/Sports Federation
PLEASE ATTACH CERTIFIED COPIES OF THE FOLLOWING DOCUMENTS
Document No.
Date of Issue
Date of Expiry
Issuing Authority
Birth Certificate
Passport
School Certificate
(verifying age group)
National Identity Card
Place of Birth
Name of the Hospital
Father’s Name
Father’s Date of Birth
Photograph of subject
(Paste here)
Mother’s Name
Mother’s Date of Birth
Parents’ Date of Marriage
Brothers/Sisters Date of Birth
(in chronological order)
Step brothers/sisters not to be
included
Age as on tournament cut off date
I have been explained that the age verification protocol shall may involve Physical including external genitalia examination ,dental examination and radiographic examination and
findings shall be accepted by me.
Signature of the
Player
Date
:
SECTION 2 - PHYSIOLOGICAL AGE: To be filled in by ISSRA Doctor or Team Physician
Physical Characteristics
Height
cms:
Weight
kgs:
BMI
Physical Appearance:
Ecto/Meso/Endo
Family history
Height of the Father
Cms:
Height of the Mother
Cms:
Height of Brothers with age
1.Age
height
2 Age
height
1.Age
height
2 Age
height
Height of Sisters with age
Cms
Any Medical problem in family
SECTION 3- Dental Age : To be filled in by ISSRA Doctor or ISSRA Dental Surgeon
Space behind 3rd molar (>15 years)
Signature:
3.Age
3.Age
height
Cms
height
Signature:
SECTION 4- Bone Age: To be filled in by ISSRA CONSULTANT Doctor
Bone Age
RUS Method
TW3 Method
Special Investigation (if any)
MRI/CT Scan/X-rays
Signature:
REMARKS :
We hereby accept the ISSRA Age verification Protocol and give our consent for the player to undergo the X-ray of the wrist and hand (AP view) and any other x-ray
as advised
The details of the above protocol has been explained to the SUBJECT AND PARENTS/GUARDIAN
CONCLUSION
Bone Age and Height predicted
as determined by ISSRA
Consultant
Signature – Player/Guardian/Parent _________________________________________
Date _______________________________
Signature – Subject _________________________________________
Date _______________________________
Signature – Chairman, ISSRA Age Verification Board
_________________________________________
Date _______________________________
Signature – Radiological Consultant --------------------------------------------------------Signature - Dental Surgeon _________________________________________
Signature
Designated Team Physician by National federation-----------------------------------
(NOT VALID FOR MEDICO LEGAL PURPOSE)
Date _______________________________