WORLD ASSOCIATION
OF KICKBOXING ORGANIZATIONS
WAKO LIABILITY WAIVER
WAKO Older Cadets and Juniors European Kickboxing
Event: Championships
Please read the below information carefully, complete the requested information, date and sign under you name. This form must be completed and
returned to a Weight Control official when registering.
Name: MELNYK ANASTASIIA Sports ID: ZFRP1SKY
DOB: 14.07.2008 Country: Ukraine E mail Address: melniknaste14@[Link]
Weight Class: -42 Style: Tatami : KL, LC
LIABILITY WAIVER:
I, the undersigned hereby confirm and agree to the following:
- I have adequate Medical insurance to cover my participation during this event;
- I, the undersigned, do herby declared that I am currently and prior to leaving my country was in good
physicalcondition and I had not suffered from any injury, infection or disability label to affect my capacity to
compete in thecurrent WAKO event;
- I release the event promoter, WAKO, WAKO’s officers, the WAKO organising committee, the WAKO (IF)
Board,WAKO members and WAKO Continental Board its servants/agents, volunteer committee and referees from
anyclaims and any loss, damage sustained while participating in the above mention event;
- I understand and I am fully aware that I am participating in a contact sport and may in the normal courseof
events sustain an injury while competing;
- In case of emergency (injuries, cuts etc.) and in any case whenever it is required by the WAKO MedicalRules, I
agree that the medical staff on duty can proceed to any examination they deem opportune;
- therefore, I assume full responsibility for all of my actions during and connected with this event I also agree
thatmy attendance and or performance may be photographed, filmed or taped and used by WAKO, event
promoterand/or their respective authorized agents. I waive any compensation thereof.
I, the undersigned, hereby authorize:
- free of charge, without time limits, any publication and/or dissemination of my pictures and videos on
WAKOwebsite, on any social channel (Facebook, etc.), on printed paper and/or on any other means of
communication;
- the storage of the photos and videos in the WAKO's archives and acknowledges that the pictures and the
videoswill be used for informational and promotional purposes.
- the processing of your personal data for the management of all activities related to the organization of the event.
This authorization may be revoked at any time by written communication to be sent by e-mail to the address
administration@[Link]
I hereby undertake and agree to abide all WAKO Rules and Regulations including WADA / WAKO Anti-Doping rules and
agrees to be tested if requested to do so. I will treat my fellow competitors, officials and referees with, Respect, Integrity,
Fair Play and Honour.
I also declare that, pursuant to Regulation (EU) 679/2016 (GDPR), I am aware that the data collected through this
document will be processed for the purposes described in WAKO Privacy Notice and that I have taken vision of the latter
pursuant to art.13 GDPR.
I declare to have read and understood the content of this document.
Place and Date:_______________________________ Signature:_______________________________
For a kickboxer under the age of 18 signature of Parent or Legal Guardian:_______________________________
WAKO HQ : VIA [Link] 18, 20900 MONZA (MB) ITALY
Tel: + 393450135521- Fax: + 39039232 8901 - E-mail: barnaraf@[Link]
WORLD ASSOCIATION
OF KICKBOXING ORGANIZATIONS
WAKO MEDICAL QUESTIONNAIRE
SPORTS MEDICAL EXAMINATION
WAKO Older Cadets and Juniors European Kickboxing
Event: Championships
Please read the below information carefully, complete the requested information, date and sign under you name. This
form must be completed and returned to a Medical Control official when registering.
Name: MELNYK ANASTASIIA Sports ID: ZFRP1SKY
DOB: 14.07.2008 Country: Ukraine E mail Address: melniknaste14@[Link]
Weight Class: -42 Style: Tatami : KL, LC
Yes No
Did you have any illnesses earlier? X
Were your born with any of your body partsmissing? X
Have you ever been treated in hospital? X
Do you take any medicine on a regular basis? X
Do you take any food complementary substances? X
Have you ever fainted during or after training? X
Have you ever had any chest pain? X
Have you ever had high blood pressure? X
Have you ever had any skin diseases? X
Do you have any dermatological complaints at the moment? X
Do you suffer from asthma? X
Do you have any problems related to your bones, joints, tendons, or muscles? X
Have you ever had a skull injury accompanied with a loss of consciousness? X
Did you have headache in the past 10 days? X
Do you have teeth braces? If yes please attach the medical certificate! X
Are you often on a diet X
Please give further details on answers with "YES"!
__________________________________________________________________________________________________
__________________________________________________________________________________________________
I officially declare that I am fully responsible for my answers given above. I also declare that, pursuant to Regulation
(EU) 679/2016 (GDPR), I am aware that the data collected through this document will be processed for the purposes
described in WAKO Privacy Notice and that I have taken vision of the latter pursuant to art.13 GDPR.
Place and Date:_______________________________ Signature:_______________________________
For a kickboxer under the age of 18 signature of Parent or Legal Guardian:_______________________________
WAKO HQ : VIA [Link] 18, 20900 MONZA (MB) ITALY
Tel: + 393450135521- Fax: + 39039232 8901 - E-mail: barnaraf@[Link]
WORLD ASSOCIATION
OF KICKBOXING ORGANIZATIONS
NON-PREGNANCY DECLARATION
for FEMALE KICKBOXERS 14 year and older
WAKO Older Cadets and Juniors European Kickboxing
Event: Championships
Please read the below information carefully, complete the requested information, date and sign under your name. This form must be completed and
returned to a Medical Control official when registering.
Name: MELNYK ANASTASIIA Sports ID: ZFRP1SKY
DOB: 14.07.2008 Country: Ukraine E mail Address: melniknaste14@[Link]
Weight Class: -42 Style: Tatami : KL, LC
I declare that: I am not pregnant.
I understand the seriousness of this statement and accept full responsibility for it. In the case that this declaration is
subsequently shown to be inaccurate or untrue and I suffer any related injury or damage during the competition, I on
behalf of myself, my heirs, executors and administrators, waive and release any and all claims for damages I may have
against WAKO (including its officials and employees), the organizers of the competition (including the Organizing
Committee and/or the Host Federation) and the Competition Venue owners for such injury or damage.
I officially declare that I am fully responsible for the statement given above. I also declare that, pursuant to Regulation (EU)
679/2016 (GDPR), I am aware that the data collected through this document will be processed for the purposes described
in WAKO Privacy Notice and that I have taken vision of the latter pursuant to art. 13 GDPR.
Date:_______________________________ Signature:_______________________________
For a kickboxer under the age of 18 signature of Parent or Legal Guardian:_______________________________
WAKO HQ : VIA [Link] 18, 20900 MONZA (MB) ITALY
Tel: + 393450135521- Fax: + 39039232 8901 - E-mail: barnaraf@[Link]
WORLD ASSOCIATION
OF KICKBOXING ORGANIZATIONS
COVID-19 HEALTH QUESTIONNAIRE (*)
First Name: MELNYK Last Name: ANASTASIIA
National Federation/Club National federation of kickboxing of Ukraine WAKO
Please, cross the proper: Kickboxer X Referee/Judge Other official
Age category OC Kickboxing discipline: KL, LC
E mail Address: melniknaste14@[Link] Phone Number +380997544379
Have you experienced any of the below symptoms in the last 14 days?
YES NO
Body Temperature ≥37.5°C X
Dry cough X
Nasal congestion X
Sore throat X
Difficult breathing X
Headache X
Conjunctivitis X
Muscle aches and pains X
Diarrhea or vomiting X
Loss of taste and/or smell X
Fatigue without a known cause X
Rash on the skin or discoloration of fingers or toes X
YES NO
Have you had a closed contact (within 1.5 meters for 15 minutes
or more cumulatively over a 24-hour period) with an individual X
infected with the COVID-19 virus in the last 14 days?
In addition, I confirm that in case I have had COVID-19, I have had a medical clearance before resuming training, stating that I am
fit for competitive kickboxing.
DECLARATION: “I declare that, pursuant to Regulation (EU) 679/2016 (GDPR), I am aware that the data collected through this
document will be processed for the purposes described in WAKO Privacy Notice and that I have taken vision of the latter
pursuant to art.13 GDPR.”
Date:_______________________________ Signature:_______________________________
For a kickboxer under the age of 18 signature of Parent or Legal Guardian:_______________________________
* Hand in at the onsite registration
WAKO HQ : VIA [Link] 18, 20900 MONZA (MB) ITALY
Tel: + 393450135521- Fax: + 39039232 8901 - E-mail: barnaraf@[Link]
