HEALTH FORM

HEALTH FORM
12^ MEZZA MARATONA DI FUCECCHIO
5 MARZO 2017
PLEASE USE BLOCK LETTERS ONLY

I, Dr. (name, surname). ________________________________________________________
born (city, country) ____________________on (dd/mm/yyyy)____________
complete address of studio ________________________________________________________
Phone number ______________________________________________________________
declare myself fully responsible and accept the consequences for falsely declaring that Mr/Ms (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 a 42, 195 metre marathon according to current laws.
This certificate is valid one year from this date
Date_____________________________
Doctor’s signature_____________________________________
Doctor’s stamp_______________________________________