4 ICF PARACANOE ATHLETE CERTIFICATE OF DIAGNOSIS Please note this form must be completed in English The person below is required to undergo ICF Paracanoe Athlete Classification to compete at International level of their chosen sport. To assist the classification process a confirmation of the medical diagnosis is required. (The ICF acknowledges the work of the IVF Adaptive paddling program in developing this document.) Family Name: Given Name: Sex: M F Date of Birth: (day/month/year) Athlete signature Medical details (This section must only be completed by a medical doctor) Athlete diagnosis How long has the athlete had this condition? Is the condition: Stable? Deteriorating? Fluctuating (Please tick one box) Are there any other factors which may affect the athletes fitness for competition? Eg: epilepsy, diabetes, heart disease, cancer, severe allergies, high blood pressure Declaration I hereby certify that I have known this patient for years and certify that the above named patient has the stated diagnosis. Doctors Name (Please Print) Address
4 ICF PARACANOE ATHLETE CERTIFICATE OF DIAGNOSIS Please note this form must be completed in English The person below is required to undergo ICF Paracanoe Athlete Classification to compete at International level of their chosen sport. To assist the classification process a confirmation of the medical diagnosis is required. (The ICF acknowledges the work of the IVF Adaptive paddling program in developing this document.) Family Name: Given Name: Sex: M F Date of Birth: (day/month/year) Athlete signature Medical details (This section must only be completed by a medical doctor) Athlete diagnosis How long has the athlete had this condition? Is the condition: Stable? Deteriorating? Fluctuating (Please tick one box) Are there any other factors which may affect the athletes fitness for competition? Eg: epilepsy, diabetes, heart disease, cancer, severe allergies, high blood pressure Declaration I hereby certify that I have known this patient for years and certify that the above named patient has the stated diagnosis. Doctors Name (Please Print) Address
5B_Revised_Dr_Certificate-2016.docx