RESPONSIBILITY COMMITMENT

Name*

First NameLast Name

Email*

example@example.com

Date of Birth*

Date

Country*

Category*

Team Name F30*

Team Name F35*

Team Name F40*

Team Name F45*

Team Name F50*

Team Name F55*

Team Name F60*

Team Name F65*

Team Name F70*

Team Name M30*

Team Name M35*

Team Name M40*

Team Name M45*

Team Name M50*

Team Name M55*

Team Name M60*

Team Name M65*

Team Name M70*

Team Name M75*

Team Name M80*

Team Name M85*

Team Name*

My address during the championship*

1. STATEMENT: As a participant in the FIMBA World Maxibasketball Championship, knowing the risks of the competition, I hereby declare that I am solely responsible for any material or moral damage, injuries, permanent or partial disability that I may suffer, including my death and loss or damage caused by my participation in the tournament, taking into account my express desire to participate in this championship and my physical fitness to practice sports, certified by a doctor. I expressly declare my responsibility for the damages expressed, current or future, with scope to my heirs, executors, administrators and attorneys-in-fact.

2. MEDIA RELEASE: I hereby grant the Organizing Committee of this championship, FIMBA and their licenses the unconditional right to use, record, publish, broadcast and otherwise exploit at this discretion in any form of media, art advertising, trade, visual documentary, promotional material, merchandise or film coverage of any kind, my performance in the games and to use my name, likeness, voice and biographical in connection therewith, without compensation to me. I also waive the right to inspect and/or approve any product or the copy that may be used in connection therewith, or the use to which it may be applied.

3. OBSERVATION OF RULES: I agree to abide by all rules and regulation issued for this tournament, for the category, and observes all written and oral instructions given by authorized personnel of the Organizing Committee and FIMBA at the championship. I agree that failure to comply with the designated rules may result in my disqualification or expel from the games.

4. PROOF OF AGE: I acknowledge and agree that the players must have reached the age category before or during this calendar year. I accept that I will be required to provide a proof of age when it is required.

5. DECLARATION OF HEALTH: As a player of the Maxibasketball category, I declare that I am in adequate physical, mental and health conditions to participate and compete in this tournament to which I have voluntarily registered. I declare that I have a Physical Fitness certification issued by a doctor in the last six months, assuming all responsibility in case of being defective or having falsified the data or the certification. I also declare that I am aware of all the risks inherent to the training and competition of the category and that I accept my personal responsibility and I waive, for any injury, injury, accident or illness, including possible permanent disability and death that I may suffer during the tournament. I know the temperatures of the region and I voluntarily decide to compete in this tournament.

6. MEDICAL RELEASE: In event I sustain an injury or illness while participating in the games, I hereby authorize attending medical personnel to perform and administer such emergency and nonemergency medical attention, as they, in their absolute discretion, deem necessary. I hereby release all attending medical personnel from any and all claims, damages, and liability arising out of acts or omissions in connection with delivery of emergency or non-emergency medical treatment to me. I declare that I am responsible for the payment of any medical transport, medical costs and other medical services. The Organization Committee is not accountable for my injuries, damages and/or my health consequences.

7. HEALTH AND MEDICAL INFORMATION: Please answer YES or NO to each of the following questions. For each answer answered YES, explain and provide the details and explain if it has been medically recommended or has been prohibited from practicing sports. Have you been treated or diagnosed, or have been recommended a treatment in the last five (5) years of the following:

Heart problems or artery disease such as a heart attack, stroke, aneurysm, arteriosclerosis, chest pain, rheumatic fever, or heart murmur*

NOYES

Hypertension*

NOYES

Skeletal muscle problems or neuromuscular problems*

NOYES

Alcohol or substance abuse problems, mental or nervous disorders*

NOYES

Diabetes or other endocrine problems*

NOYES

Are you taking any medication? (except antibiotics or contraceptives)*

NOYES

If YES, which ones?*

Have you gained or lost more than 10 kilos in the last year?*

NOYES

If YES, did you gain or lose?*

Have you been hospitalized or have you had any surgery in the last five (5) years*

NOYES

If YES, why?*

Are you allergic to any medications?*

NOYES

Are you pregnant?*

NOYES

Do you have any medical conditions that have not been exposed above?*

NOYES

By signing below, I certify that I have read, understood and waived certain rights that are a consequence of my exclusive responsibility. My answers and statements are true and complete. I understand the present statement is under this country laws and I agree to submit, expressly waiving any other jurisdiction or jurisdiction to the International Sports Arbitration Court (CADI).

Date*

Date

Signature*