Medical Certificate

The certificate is in accordance with New Caledonia law. However, in order to make sure that we treat all the certificates sent from different countries correctly, it is compulsory to use this form, no other will be accepted. This medical certificate has to be filled in, dated and signed by the doctor, who stamps it and specifies his professional number. This certificate must be sent to the organizer by 31 of May 2019. Failure to do by this date will lead to the annulment of registration without reimbursement.  Nobody will attend the race without the medical certificate.

MEDICAL CERTIFICATE

To be filled by You, the participant:

First name(s) . . . . . . . . .. …………………… . . . . …………… Surname: . . . . . .. …………….………………

Date of birth: ___ / ___/ _____,

Address: …………………………………………………………………………………………………………

Town: ….………………  Country: ………………….………  Contact number: ……….………….………….

Emergency contact name: ……………………….  Emergency contact number: ……………………………….

To be filled by your GP / Doctor / Medical Practitioner

I, the undersigned doctor of medicine ………………………………………………………………………….

certify that the careful medical examination of above participant does not reveal any contraindication to the practice of competitive ultra-trail running including UTNC 2019. And that the above participant is aware of the listed medical recommendations attached.

Professional stamp/seal:                                              Professional number:…………………………………

Date: ___ / ___ / ______

Signature of doctor: