1 Submitter's Information2 Medical Upload This form is for athletes who have already completed their Competitive Membership with Muaythai Canada, but need to submit or update their medical information. Annual Medical Declarations and blood work are only valid for 12 months from the date shown on the completed form.The athlete is a member of a club located in...*(Please Select)ABBCMBNBNLNTNSNUONPEQCSKYTOutside CanadaI am...*An athlete submitting my own medical documentsA parent/guardian submitting on behalf of my childA coach/administrator submitting on behalf of an athleteAthletes from Ontario Clubs must upload their medicals to the Muaythai Ontario Medical Form. Submitter's InformationYour Name* First Last Your Email* Enter Email Confirm Email Athlete InformationAthlete Legal Name* First Last Athlete Email* Enter Email Confirm Email Athlete's Club Affiliation*Athlete Age (Years)*Please enter a number greater than or equal to 0.Athletes age 15 an younger are not required to submit laboratory blood tests in order to participate in competition. When an athlete has reached 16 years of age HIV, Hepatitis B Surface Antigen, and Hepatitis C Antibody screening blood tests are required for judged full contact competition.Coach InformationCoach Name* First Last Coach Email* Enter Email Confirm Email Send a copy of the uploaded medical documents to my coachMedical documents are personal, private information and do not need to be submitted to anyone other than Muaythai Canada for approval.YesNoMedical Release Signature*By signing this form I authorize Muaythai Canada to release confidential health information about me, by releasing a copy of my medical records to the coach email address completed above.Medical Document InformationI understand that for competition in Alberta I am required to bring a physical copy of my medical information to each event.* Yes Please select the medical documents that you will be uploading* Annual Medical Declaration Laboratory Blood Tests Clearance for Returning to Competition After Injury Annual Medical Declaration UploadUpload the Annual Medical Declaration here*All athletes participating in full contact competition must have a completed Annual Medical Declaration that has been completed no more than 12 months prior to the competition date. Both pages must be uploaded at the same time for a medical to be processed. File types: .jpg, .jpeg, .png, .pdf Maximum 20 MB. Drop files here or Accepted file types: jpg, jpeg, png, pdf. Lab Test UploadUpload the scans of the completed HIV, HEP B, and HEP C tests here*All athletes age 16 years and older participating in full contact competition must have HIV, Hepatitis B Surface Antigen, and Hepatitis C Antibody screening blood tests that have been completed no more than 12 months prior to the competition date. All tests must be uploaded at the same time to be processed; individually uploaded tests will not be recorded. File types: .jpg, .jpeg, .png, .pdf Maximum 20 MB. Drop files here or Accepted file types: jpg, jpeg, png, pdf. Clearance for Returning to Competition After an InjuryUpload the scans of the completed medical clearance letter*The medical clearance letter must be completed by a medical doctor. In the event that an athlete was on a medical suspension, the athlete must complete the duration of the suspension even if the medical clearance letter is completed in advance. File types: .jpg, .jpeg, .png, .pdf Maximum 20 MB. Drop files here or Accepted file types: jpg, jpeg, png, pdf. Document Processing TimesRush Information Processing*Rush information processing is required when submitting information 2 to 5 business days prior to an event an individual is participating in. Information submitted 1 business day prior to an event will not be processed. Refer to image below for a rush fee schedule: "OK" - Memberships are processed without a rush fee "RUSH" - Only Memberships with a rush fee are processed "NOT PROCESSED" - Memberships are not processed on these days, even with rush fees "EVENT" - Event day I do not need Rush Processing ($0)I need my information rushed to be processed within 5 business days ($30)CAPTCHAPayment InformationCoupon Coupons are generally only used for administrative purposes.Rush Information Processing Fee Price: CAD$ 30.00 CAD HST (15%) Price: CAD$ 0.00 CAD GST (5%) Price: CAD$ 0.00 CAD Total CAD$ 0.00 CAD Billing InformationCredit Card* American ExpressDiscoverMasterCardVisaJCBMaestro Card Number Expiration Date Month010203040506070809101112 Year20192020202120222023202420252026202720282029203020312032203320342035203620372038 Security Code Cardholder Name Cardholder Email* Enter Email Confirm Email Cardholder Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe This iframe contains the logic required to handle Ajax powered Gravity Forms.
