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Association Internationale pour le Dveloppement de l'Apne - Rue du Petit-Beaulieu 4 - CH - 1004 Lausanne /VD - Suisse version 2009-v1.0, COPYRIGHT AIDA INTERNATIONAL 2007 [page 1 of 2]
Signed: _________________________________________________________________________
Date: _______________________________________________ * If the Freediver is aged less than 18 years, this must also be signed by a parent/guardian Signature of participants parent or guardian: _________________________________________
-------------------------------------------------------------------------------------------------------------------------------------PHYSICIAN TO COMPLETE (If any YES box from Page 1 was ticked) ( ( ) I find no medical conditions that I consider incompatible with freediving ) I am unable to recommend this individual for freediving
Physicians Signature: ____________________________________________________________ Physicians Name: ________________________________________________________________ (IN BLOCK CAPITALS) Date: ______________________________________________ Physicians phone number: ________________________________________________________ Physicians Stamp or Postal Address:
My signature on the above verifies that I have completely reviewed this applicants Medical Statement and find no counter-indications for freediving.
Association Internationale pour le Dveloppement de l'Apne - Rue du Petit-Beaulieu 4 - CH - 1004 Lausanne /VD - Suisse version 2009-v1.0, COPYRIGHT AIDA INTERNATIONAL 2007 [page 2 of 2]