38 Kew Road | Valhalla Pretoria | 0185 | South Africa Tel/Fax: + 2712651 0328 | Cell: + 27 083 770 6022 E-Mail: | Web Site:



FIGHTERS NAME:______________________________________________________________

AGE:__________________________________DATE OF BIRTH:________________________




I, ____________________________________hereby declare that I am fit and in excellent health condition to participate in this kick-boxing event and that I am not on any medication or any form of drug. I also exempt the event organizers, trainers, helpers and officials of all cases of personal injury that may occur at the event and that the first aid / medical officials may attend to me when injured. Should I have to receive treatment at a hospital or any medical institution due to any injury I will be responsible to pay my own expenses. I hereby indemnify South African Kick-Boxing and or any person employed or assisting South African Kick Boxing against any liability for any damage (s) and or any injury (s) of any kind, to my person and I or property during any of the activities offered by South African Kick-Boxing, which I choose to participate in. In a case of a minor (any person under the age of 21 years of age) I confirm that my parent (s) and or legal guardian who has been notified either personally, telephonically or electronically of my intended participation in the South African Kick-Boxing activities and has either personally, telephonically or electronically given his / her / their permission to do so. I understand this indemnity form clearly and was not unduly influenced to sign it. I sign this form freely and voluntarily and understand that should I get any form of injury that it will not be due to the negligence of the event organizers and or management and or any other person involved. I understand that Kick-Boxing is a contact sport and voluntarily agree to participate. I confirm that I understand the rules of Kick-boxing and should I do full contact I am fully aware of the dangers there of. I confirm that all previous injuries I might have had, has been checked out by a medical doctor and this doctor declared me fit for participation in this kick-boxing event and should I have an injury or medical condition which might be aggravated by the nature of kick-boxing I will not participate.

In case of emergency:

Contact person:______________________________________________________


SIGNED THIS__________________DAY OF__________________

Fighter's signature Instructor's signatureParent's signature if fighter is Under 21 years old
_________ _________ _________
Witness Witness Event organizer

Instructor's Tel No | cell no:____________________________________

Medical (will be done at the weigh-in)


Blood Pressure:__________________Lungs clear:__________________

Remarks:_______________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________

May / May not participate:________________________


Physician signature


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