Download Para-Athletes with a Physical Impairment

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.
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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
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Female
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Date of Birth
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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:
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 Impaired Muscle Power:
o
If spinal cord injury (SCI)
 Level of lesion:
 Complete or incomplete:
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 Impaired Joint Range of Movement
o Joint/s affected::
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Neurological:
o  Hemiplegia
o  Hypertonia
o  Ataxia
o  Athetosis
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 Short Stature
o Height:
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 Leg length Difference
o Length Difference:
 Diplegia
 Quadraplegia
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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:
________________________________________
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PNZ Provisional Classification Form
SECTION 2 – SPORTING HISTORY
(Can be completed by athlete)
What Sport/s do you require a provisional classification in?
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Are you able to walk?
 yes
no
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Do you use crutches or a mobility aid?
 yes
no
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Are you a full time wheelchair user?
 yes
no
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Years involved in the sport:
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Do you train with a coach?
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Number of training sessions a week:
Type:
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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
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