Meia Maratona de Veneza

VENICEMARATHON LIABILITY WAIVER FORM VENICEMARATHON HEALTH CHECK LIST AND TERMS Please read carefully and sign below to confirm that you agree with the following 1) I (Participant) will pay attention to my health, keep myself in good physical condition, and train sufficiently before I participate in the race. My participation will be with self-responsibility. I will also use the pre-race Health Check list, reported below**, to confirm my physical condition. If I am not in good physical condition, I will cancel my participation in the race or pay careful attention to my condition during the race. 2) If I am injured, have an accident, or become sick during the race, I will have no objection to receive first aid. I will fill out all the medical information and emergency contact details reported on the back side of the bib number, as I know there are important details to assist me in case of need. 3) Nobody will run on my behalf. If somebody should run on my behalf, I will not hold the organizers responsible for any accident he or she may have during the race. If it should be revealed that somebody ran on my behalf, I will comply with the organizers’ instructions, including cancellation of any official commendation or entries for the Venicemarathon in future. 4) I register without any failure or deceit in my application including entry qualifications or participation time limit for this race. 5) I agree that the right to release any materials during the race, Exposport or associated event such as videos, photographs, articles, TV programs, newspapers, magazines, websites or posters and flyers for promoting the next Venicemarathon events belongs to the organizer. 6) I will enter the start area from the designated entrance gate. (It is prohibited to enter from other gates). 7) I have read the terms and conditions set forth in Marathon rules reported on the online registration form and on the website and agree to abide by them as a condition of my participation. **A HEALTH CHECK is required before participating in the Venicemarathon. Each runner must check the followings and join the race on his/her responsibility. a) Please, consult your primary care doctor about participation in the race if any of the following items (1 to 5) are applicable to you. Please, have a physical examination and a cardiac examination under the supervision of your primary care doctor. You are not required to submit any medical certificates. This health check list is aimed to assist your own health check. If you join the race, you are responsible for your actions. 1. Are you currently undergoing treatment for, or have you ever been diagnosed with a cardiac disease (cardiac inflation, angina pectoris, cardiomyopathy, valvular disorder, congenital heart disease, irregular heartbeat, etc.)? 2. Have you ever suddenly lost consciousness (fainted)? 3. Have you ever felt chest pain or dizzy when you were exercising? 4. Has your relative suddenly died because of a so-called “heart failure” (sudden death)? 5. Has it been more than a year since your last physical examination? The following items (6 to 9) are risk factors for cardiac infarction and angina pectoris. Please consult your primary care doctor if any of these are applicable to you and keep your physical condition stable before participating in the race. 6. Is your blood pressure high (hypertension)? 7. Is your blood-sugar level high, or have you ever been diagnosed with diabetes? 8. Do you have a high LDL cholesterol level or neutral fat level (hyperlipemia)? 9. Do you smoke? Your primary care doctor is the physician closest to you who can help you manage your health and physical condition. Carefully choose your primary care doctor and discuss your required physical examinations, and whether you can participate in the race. I hereby comply with the terms described above and after reading the health check list I confirm I can participate in the race. Signature (must be signed, not typed, by the runner) __________________________________ ___________________________________ ______________________________________________ write your name in block letters write your date of birth Emergency contact in case of accident relationship _________________________________ _______________________________ ______________________________________________ Name of the contact person phone number -- 1 of 1 --