Para-ArcheryClassificationIntakeForm

Thisformconsists of two parts. The first part is a request form, which needs to be filled and signed by National Federation representative. The second part is the evidence of health condition and needs to be completed bya physicianfamiliarwiththeapplicant’s medicalcondition, disease, orinjury mustsignthecompleteddocumentandprovidenationalmedicalsociety orboardofpracticeinformationforverificationpurposes.Both parts mustbecompleted electronicallyintheEnglishlanguageandreceived by World Archery ()30 days prior to the classification.

Asthisformrepresentsthefirststepintheclassificationprocess,theinformationprovidedmustbehonest,accurate,andverifiable. Successfulcompletionofthisformdoesnotindicatethataclassificationwillbeperformed. Rather,itprovidesaconcisebasis of discussion between the applicant and classification team regarding theapplicant’spotentialforbeingsuccessfullyclassifiedasapara-archerycompetitor.

The completedform must be submittedless thanthree monthspriortoclassification

scheduling.

Theinformationprovidedonthisformisessentialtoverifythatthemedicalcondition,disease,orinjurythattheapplicanthassustainedhasaclearimpactontheirabilitytofunctioninthesportofarchery.

Electronic portrait picture (passport type, JPG) is required together with this form as a separate attachment.

Event______

Archer Details: The archer must bring with them evidence of their medical condition in English& Passport. The archer must bring all special equipment & assistive devices to the classification appointment.

Family Name______

Given Name______

Date of birth (DD/MM/YYYY)______

Country______

Type of request (crossonly one type of request) new classification☐ review with the fixed date☐ reclassification☐

Date ______Place ______

Signature of National Federation representative______

Stamp of National Federation

Para-ArcheryClassificationMedicalInformationIntakeForm

ApplicantInformation

This form needs to be completed electronically (hand written forms not accepted)

Family nameand Givenname
(as passport)
DatePlaceofBirth(DD/MM/YYYY)
NationalGoverningBody(MemberAssociation)
This part is filled only if reclassification is requested
Reason of the reclassification request (explain the change of the eligibility according to previous) classification)
PrimaryDiagnosis
(the majormedicalcondition,disease,orinjury that impactstheapplicant’sabilitytoperformthesportofarchery)
Dateofdiagnosis(DD/MM/YYYY)
Significantfunctionallimitationsand/or
impairmentsassociated with thePrimaryDiagnosis
Summary of SpecialTests that confirmthePrimary
Diagnosis(mayincludeinformation
provided by X-rays,MagneticResonanceImages,Diagnostic
Electromyography,
orothertestsdeemedappropriatebyatreatingphysician)

Para-ArcheryClassificationMedicalInformationIntakeForm

SecondaryDiagnosis
(asecondarymedicalcondition,disease,orinjurythatwhencombined withtheprimarymedicaldiagnosisimpactstheapplicant’sabilitytoperformthesportofarchery)
Dateofdiagnosis
(DD/MM/YYYY)
Significantfunctionallimitationsand/orimpairmentsassociated with theSecondaryDiagnosis
Summary of SpecialTeststhatconfirmtheSecondaryDiagnosis (mayincludeinformationprovided by X-rays,Magnetic ResonanceImages,DiagnosticElectromyography,
orothertests
deemedappropriatebyatreatingphysician)
Any other medicalconditions, diseases,injuries,or
Extenuatingcircumstancesthat
mayimpactthe
applicant’s ability toperformthesportofarchery

Para-ArcheryClassificationMedicalInformationIntakeForm

PhysicianInformation

SurnameFirstname
Signature
PhysicianNationalMedicalSocietyorNationalBoardofPractice
PhysicianRegistrationNumber/
Notapplicable