Health Declaration Form for Participants in Kapaim Active Events

Health Declaration Form for Participants in Kapaim Active Events
*If someone is picking up the kit on your behalf, please attach this signed document.
Part A: Medical Questionnaire
Please thoroughly read the questions below and answer honestly by marking the
relevant answer.
1. Did your doctor say that you suffer from heart disease? Yes/No
2. Do you feel pain in your chest (please answer each of the following options)
a. When at rest? Yes/No
b. While doing day-to-day routine activities? Yes/No
c. During physical activity? Yes/No
3. During the past year, (please answer each of the following options)
a. Did you lose your balance due to dizziness? Mark no, if your dizziness
was caused from hyperventilation (including during excessive physical
activity) Yes/No
b. Did you lose consciousness? Yes/No
4. Has a doctor diagnosed that you suffer from asthma and as a result, in the last
3 months (please answer each of the following questions below)
a. You needed to take medicine? Yes/No
b. You suffer from shortness of breath or wheezing? Yes/No
5. Has any one of your immediate family died (please answer each of the following
a. From heart disease? Yes/No
b. From sudden death at a young age (men before the age of 55 and
women before the age of 65)? Yes/No
6. During the past 5 years, has your doctor suggested you do physical activity
under medical supervision? Yes/No
7. Do you suffer from any chronic disease that is not mentioned above that might
limit or prevent you from doing physical activity? Yes/No
8. For pregnant women: Is this pregnancy considered high risk or have any of your
previous pregnancies been considered high risk? Yes/No
Part B: Guidelines
If you marked ʺyes" to any of the questions in Part A of this form, in order to
participate in the event, you must provide Kapaim Active with a medical certificate
signed by a physician that clearly specifies that participating in this sporting event
will not pose a risk to your health. Kapaim Active will allow participation in the
event only upon the presentation of a medical certificate that has been issued
within the last 3 months. You must bring this signed and valid medical form
with you to the registration kit pick-up.
Part C: The Declaration
I hereby declare that all the information that I have provided is accurate and I
am physically fit to participate in the event
I hereby declare that I intend to participate in a sports activity that demands
significant physical effort.
I hereby declare that I am healthy and fit for the event and have trained
accordingly for it.
I understand that my participation in this event, under the circumstances that
I am not adequately in form physically, may danger my health.
I am aware that the organizing committee of the event, the hosting party, the
organizers and producers and sponsors will not undertake any responsibility
for any harm that I may endure, including bodily harm that may occur prior to
the event, during or thereafter, nor are they responsible for any lost or
damaged belongings.
I know that if during the week of and prior to the event, I suffer or if I suspect
that I suffer from any sickness, including fever, digestive issues or cough,
then I must consult a physician prior to the event and receive permission to
I hereby declare that I understand this medical questionnaire and health
declaration form and completed it myself. I declare that I have provided
full and accurate information about my past and present medical situation
according to the questions above. I am aware that if there is any change in
my medical situation, I must consult with a physician regarding
participating in the event.
First name: ____________________
Last name: ___________________
ID/passport number: ____________________
Date: _______________
Signature: _______________________
Part D: Parental Consent for Minors (those under 18 years of age)
Participants under 18 years of age must include parental consent with his/her
health declaration by providing the signature of a parent below.
I permit my son/daughter to participate in the sporting event and confirm that
he/she is healthy and in proper physical condition to do so.
Full name of parent: _____________________
ID/passport number: _____________________
Signature: __________________