Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
PROVISIONAL CLASSIFICATION FORM PARA-ATHLETES with PHYSICAL IMPAIRMENT Classification is integral to Para- Sport as it provides the structure for fair and equitable competition. Each Para- Sport has a different sports specific Classification System. A Provisional Classification is a temporary classification that enables a Para-Athlete to enter a Para-Sport event for the first time. It places a Para-Athlete into a competition category where they compete against other athletes with a similar activity limitation resulting from impairment. A Provisional Classification is valid for two years from time of issue or earlier if the Para-Athlete can be assessed by a classification panel for a National Classification. PLEASE NOTE FOR SECONDARY SCHOOL STUDENTS A provisional classification is valid for the length of time the Para-Athlete is at secondary school or earlier if they receive a National Classification. This Classification Form needs to be completed by Para-Athletes with a Physical Impairment. Sections 1 and 3 may be completed by the athlete. Section 2 MUST be completed by the athlete’s medical physician. Athletes with a Visual Impairment must complete a Visual Impairment Provisional Classification Form (available on the PNZ website). Athletes with an Intellectual Impairment must complete the Intellectual Impairment Provisional Classification Form (available on the PNZ website). Forms are to be emailed to the PNZ Classification Manager NO LATER than four weeks before the event at [email protected] Provisional Classification certification will be sent via email. SECTION 1 – ATHLETE INFORMATION (Can be completed by the athlete, or their representative) Last Name: First Name: Address: Suburb: City: Postcode: Phone (Hm): ( Mobile: ) ( ) Email: Male Female Date of Birth 1 PNZ Provisional Classification Form SECTION 2 – MEDICAL INFORMATION (MUST be completed by athlete’s medical physician) State Medical Diagnosis (Health Condition) and Resulting Loss of Function (Impairment): Is the Health Condition: (tick) Permanent: Non Permanent Congenital Acquired Date: Impairment Type/s: (tick) Limb Loss or Deficiency o Limb/s : o Level of amputation: Impaired Muscle Power: o If spinal cord injury (SCI) Level of lesion: Complete or incomplete: Impaired Joint Range of Movement o Joint/s affected:: Neurological: o Hemiplegia o Hypertonia o Ataxia o Athetosis Short Stature o Height: Leg length Difference o Length Difference: Diplegia Quadraplegia 2 PNZ Provisional Classification Form Additional recent and relevant medical documentation MUST be enclosed if: o Athlete has a medical diagnosis and/or impairment that presents with no clear signs and symptoms. o Athlete has a complex or rare health condition or multiple impairments. (Documentation could include photos of impairment). o Athlete has a spinal cord injury (Recent ASIA scale results to be enclosed). o Athlete has a neurological impairments of ataxia, athetosis or hypertonia (A Modified Ashworth Scale score to be completed by a physician or physiotherapist and enclosed) o Athlete has a loss of muscle power or range of movement. (Muscle power test or range of movement test score to be completed by a physician or physiotherapist and enclosed). Medication (Regular) Medical Declaration (To be signed by athlete’s medical physician) Name: _____________________________________________ Medical Specialty: _____________________________________________ Registration Number: ____________________________________ Address: Phone: ________________________________________________________________ ___________________________ Email: _____________________________________________ Date: _____________________________ Signature: ________________________________________ 3 PNZ Provisional Classification Form SECTION 2 – SPORTING HISTORY (Can be completed by athlete) What Sport/s do you require a provisional classification in? Are you able to walk? yes no Do you use crutches or a mobility aid? yes no Are you a full time wheelchair user? yes no Years involved in the sport: Do you train with a coach? Number of training sessions a week: Type: Number of competitions in the last 12 months: Do you compete? Seated (wheelchair user) Standing (Ambulant) Athlete Declaration I declare the information submitted on this form to be a true and accurate reflection of my sporting history. I understand that failure to give accurate information may result in me receiving an incorrect classification. I understand that I will receive a provisional classification according to the information that I submit to Paralympics New Zealand on this form. I understand that information from this classification form will be held by Paralympics New Zealand (PNZ) who may share this information with other Regional and National Bodies that are involved in your development in sport. I agree to having my photo taken and/or a video taken to support information for classification purposes. Signature of Athlete Date (or guardian if under 18) PNZ Provisional Classification Form 4