REQUIRED AMATEUR FIGHTER REGISTRATION and CONFIRMATION FORM
ALL LINES (Except One) ARE MANDATORY - ANY LEFT BLANK WILL DROP YOU FROM THIS EVENT
FIGHTER'S FULL LEGAL NAME:
DO YOU GO BY OR HAVE ANY OTHER NAME? If yes, insert here or type DL#:
FIGHTERS DRIVER'S LICENSE: STATE: NO:
FIGHTERS DATE OF BIRTH: FIGHTER'S FIGHTING WEIGHT: LBS
AMMY MIXED MARTIAL ARTS RECORD: Win: Loss: Draw: Sub Win: KOs:
AMMY KICK BOXING RECORD: Win: Loss: Draw: KOs:
AMMY BOXING RECORD: Win: Loss: Draw: KOs:
AMMY OTHER FIGHTING RECORD: Win: Loss: Draw: KOs:
DATE OF LAST BOUT: RESULT OF LAST BOUT: If a Loss, HOW?
LAST TIME YOU WERE KOed OR BOUT STOPPED YOU LOST (Date can be blank if N/A)
FIGHT WEIGHT:
HEIGHT: " '
AGE:
DATE OF BIRTH:
Dominant Hand:
REACH:
Sex:
LAST DATE BLOOD WORK WAS DONE:
LAST DATE SPORTS PHYSICAL WAS DONE:
GYM: TIME TRAINING TRAINER: PHONE:
FIGHTER'S HOME ADDRESS:ADDRESS: City: STATE: ZIP:
FIGHTER'S CONTACT PHONE NUMBER:
FIGHTER'S CONTACT EMAIL:
FIGHTER'S TRAINER'S NAME - IF ONE (Type NONE, if none):
FIGHTER'S TRAINER'S CONTACT NUMBER - IF ONE (Type NONE, if none:
FIGHTER'S TRAINER'S EMAIL:
EVENT DATE:
PROMOTERS NAME:
PHYSICAL EVENT LOCATION: THE SALISBURY CENTER, 8890 MATHIS AVE, MANASSAS, VA 20110
This is a Legal Amateur Status Registration and Confirmation Form binding You, The FIGHTER named above, The VCCS (Virginia Combat Sports Sanctioning), The Promoter (named above), The Venue (named above), any affiliates and any and all of these companies, federations or organizations associates, officials, employees and staff related to the FIGHTER AND EVENT named above. You hereby comment and agree to completely accept alone any and all Fines, Suspensions and Disciplinary Actions if you are found to be untruthful on ANY of the Questions below and You verify and confirm all of the below statements by placing a checkmark at each numbered item as well as signing your full and legal name below.
READ IT CAREFULLY AND OBTAIN LEGAL ASSISTANCE IF YOU DO NOT UNDERSTAND IT.
- Voluntary I, the undersigned, acknowledge and state that I have ACCEPTED to compete in the EVENT NAMED ABOVE on the DATE NAMED ABOVE as an AMATEUR Fighter.
- I confirm under penalty or perjury that as of the EVENT DATE noted above;
- I have Never been Paid, Contracted or Fought as a
Professional Mixed Martial Arts Fighter EVER.
- I have Never been Paid, Contracted or Fought as a
Professional Kickboxer EVER.
- I have Never been Paid, Contracted or Fought as a
Professional Boxer EVER.
- I have Never been Paid, Contracted or Fought as a
Professional in ANY Full Contact Sport EVER.
- PENALTY FINES & SUSPENSIONS FOR PRO FIGHTERS FIGHTING AS AN AMATEUR
- - I hereby agree that this Amateur Status Confirmation shall be interpreted under and construed in accordance with the Amateur Definition as noted by the VCCS (Virginia Combat Sports Sanctioning) definition of a Professional Fighter and Amateur Fighter as follows: .
-
- AMATEUR DEFINITION: One who engages in an activity as a pastime rather than as a professional; one who lacks expertise.
- AMATEUR IN SPORTS: An athlete who has never participated in competition for money. An athlete who is not paid for his/her performance. An athlete at the beginning learning levels of his/her career.
- PROFESSIONAL DEFINITION: Perfonned by persons receiving pay. An expert in a field of
endeavor. PROFESSIONAL IN SPORTS: An athlete who is paid for his/her pcrfonnance. Paid for their excellence of experience, knowledge and ability of their given sport. An athlete who plays for pay•
- - Knowing and Voluntary Excecution 1. I hereby declare that I have read this Amateur Status Confirmation in full and that I fully understand the meaning and importance of its contents. I acknowledge that this Amateur Status Confirmation is a binding confirmation among myself, the VCCS (Virginia Combat Sports Sanctioning) and the PROMOTER named above and any and ell of these companies, federations or organizations associates, officials, employees and staff.
- - Knowing and Voluntary Execution 2. I further declare and represent that I am at least 18 years of age, that I have full legal capacity to be bound by this Amateur Status Confirmation, and that I am signing this Amateur Status Confirmation of my own free will and accord.
- KO - TKO - INJURY SUSPENSIONS
- FEMALES ONLY: Are you pregnant?
- INSURANCE COVERAGE: I certify that I am in good health and conditioning and am unaware of any condition that would result in my injury or death. Any physical exam provided at this event is limited to a physical screening and not intended to provide any level of medical assurance of my ability to participate in this event. I further certify that I have submitted my blood test results showing that I am negative for HIV, Hepatitis B and Hepatitis C, I am either fully vaccinated and am two weeks or more past my final vaccination shot and/or have no signs of Covid-19 and have been tested by a medical facility accepted by VDOH and have negative results for having Covid-19 within the last 48 hours, and carry my own insurance and that any insurance carried by Promoter is subordinate to my own insurance and will provide proof of insurance upon request.
I, , declare under penalty of perjury under the rules and regulations of the VCCS (Virginia Combat Sports Sanctioning), that the foregoing information is true and correct; further I realize that any intentional misrepresentation may result in disciplinary action against me.
Executed in the City & State as listed above on the day of the month of , in the year 20 .
SIGNER Printed Name:
SIGNER is the:
