Full Exam Form - Ak Promotions

AKP Full Contact Exam Form

This form is to be filled out by all fighters and given to the event doctor for sign-off. If form is not completed and signed off by the event doctor, you cannot compete in this event.

Fighter's First Name:*
Fighter's Last Name:*
Age*
Date of Birth 00-00-0000*
Gender*
If you choose other below, please inform the Physician that you chose other and why as it may affect your participation in this event.
Have you ever had blurred Vision?
Have you ever had ANY surgical Procedures to your Eyes?
If you answer yes to the question below...please advise the physician so that information can be noted on this form.
Have you ever been diagnosed by a Physician to have any significant eye problem such as blindness, Retinal Tear, Glaucoma or other?
If you answer yes to the question below...please advise the physician so that information can be noted on this form.
Physical History: If you have had any of these items below...please note below

Asthma, Blood in Urine, Allergies, Fainting Spells,Rupture (Hernia), Chest Pains, Diabetes, Convulsion, Abnormal Bleeding, Shortness of Breath, Swollen Joints, Frequent Headaches, Chronic Cough, Any Type of Hemorrhage...Anywhere?, Have you had any type of serious head injury- Please choose yes or no below if any of the items above relates to you
When was the last time you took any type of medication or drug? (State what type and when and be specific):
Do you have any groin pain, bulging or history of a hernia? _
Do you presently have any open cuts, sores, wounds, or rashes?
When was the last time you took any type of vitamin supplement?*
Women Only: Are You Pregnant?*
Consent*
I agree to the privacy policy.
I, the competitor named here, by submitting this application understand that I am consenting to release Johnny Davis Enterprises DBA (AK) Promotions, The International Kickboxing Federation (IKF), The International Fight Sports, Officials, Event Doctors and all medical staff, The promoter of event and, or any of its sponsors, The Event Venue, Officials, owners or members and all other persons associated with this event in any capacity from any liability arising out of injuries, and or death etc., that I may incur as a result of my attendance and, or participation in this IKF Full Contact Fighting or Semi Contact Point Muay Thai / Kickboxing Sparring Tournament. Furthermore, I hereby Assume All Risk involved in aforementioned event and waive any compensation whatsoever for the use of pictures, movies, media coverage, etc., utilized by those associated with this event for profit or promotional needs, at any time. I clearly understand that the fighting aspect of this competition involves contact blows. I have read, understand and agree to abide by the rules governing this event and assume all responsibility and any associated liability for any infringement of such rules. Additionally, I am fully aware of my medical condition and hereby certify that I have my own insurance coverage and am mentally and physically fit to compete in this Kickboxing event. I also understand that a valid birth certificate / ID should be presented upon request in order to compete in this tournament. Additionally, if any information on my registration forms are found to be incorrect or fraudulent, I accept all fines and, up to including my removal from this competition and future competitions by AK Promotions and the IKF. I further agree that any registration fees, ticket sales etc. are not refundable but may be transferred to another AKP Event if applicable.
IMPORTANT:PHYSICAL EXAMINATION BY MD OR DO ONLY-Dr. NOTES BELOW
STOP: Only a Medical Doctor is to complete the information below. Any attempt for anyone else to fill out this form will be deem fraudulent.
Have you ever undergone any type of surgery? Answer Below*
Mandatory: Based on Your Observation and Review is it your opinion that fighter on this form is physically fit to compete in Full Contact Muay Thai and, or Kickboxing Fights? Dr. should answer Yes or No Below
Height*
Weight*
Pulse Rate: (R) Resting - (A) Active*
HEENT: Dr. Note below if you have any issues the following: Mouth, Teeth, Eyes, Adenopathy, Thyroid, Heart, Chest, Lungs, Abdomen, Joints, Extremities, Neuro,Reflexes, Skin, Visual Fields- Please Let Physician know...*
Blood Pressure- Rest (R) and Active (A)*
Physician To Explain Any Abnormality or "No Responses""*
VISION: Does Fighter wear Contact Lens?:*
Can Fighter see at least 20/50 Vision at 3 feet with EACH Eye & Both Uncorrected?*
Physician Name*
First Last
General Appearance of Competitor:*
General Appearance- Explained by Doctor if other than healthy or note N/A*
Doctors Phone #(000)000-0000*
Doctor's Electronic Signature*
Date of Exam*
MM slash DD slash YYYY