The Salisbury Center

Required Amateur Fighter Registration


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.

  1.  
     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.
  2.  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.

  1. PENALTY FINES & SUSPENSIONS FOR PRO FIGHTERS FIGHTING AS AN AMATEUR
    • - I fully understand that if l have not been truthful with any of the above questions that I will be responsible for the following disciplines:
      • - Suspended for a minimum of 60 days up to 12 months by the VCCS (Virginia Combat Sports Sanctioning)
      •  - The time of suspension will be determined at time of infraction by the VCCS (Virginia Combat Sports Sanctioning)
    • - In addition, I also fully understand that if l have not been truthful with any of the above questions that my Trainer listed above shall face the following disciplines:
      • - Suspended for a minimwn of 60 days up to 12 months by the VCCS (Virginia Combat Sports Sanctioning)
      •  - The time of suspension will be determined at time of infraction by the VCCS (Virginia Combat Sports Sanctioning)
  1. - 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•

  1. - 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.
  1. - 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.
  2. KO - TKO - INJURY SUSPENSIONS
    • Have you ever suffered any knockouts (KO's), technical knockout's (TKO's), or any kind of loss of consciousness in the last 30 DAYS prior to the date of this event during a bout, sparring or in any other activity?
      •  
      • If yes, please list and give dates and details:
    • - I am not under any Medical Suspension by any Sanctioning body, boxing or Athletic Commission or Medical supervisor of any kind within the last 30 days
    • - I am not under any Disciplinary Suspension by any Sanctioning body, boxing or Athletic Commission or Medical supervisor of any kind within the last 30 days
    • - I have not been Knocked Out, had my fight stopped due to excessive blows or sustained any head injuries that may have caused loss of consciousness within the last 30 days.
  1. FEMALES ONLY: Are you pregnant?  
    • Pregnancy Advisory Notic ALERT: If you participate in combative sports when you are pregnant you could have a miscarriage or you and or your fetus could suffer permanent injury or death. VCCS (Virginia Combat Sports Sanctioning), or the Promotor (named above), cannot force you to have a pregnancy test as a requirement for licensing or before a bout. However, the VCCS (Virginia Combat Sports Sanctioning) and the Promoter (named above) strongly urge you to be tested before each of your bouts. The VCCS (Virginia Combat Sports Sanctioning) and the Promoter (named above) strongly urge you to not compete if you know or think you may be pregnant. Through this notice the VCCS (Virginia Combat Sports Sanctioning) and the Promoter (named above) informs you that the VCCS (Virginia Combat Sports Sanctioning), the Promoter (named above), the Venue, any affiliates or any of its agents and the physician who conducts your pre-bout examination(s) are not responsible for any injury that you and or your fetus suffers if you compete when you are pregnant.
    • - You certify that you are not on a menstrual period during this bout/event and if so, will not fight
  2.  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:  

Leave this empty:

Signature arrow sign here


Signature Certificate
Document name: Required Amateur Fighter Registration
lock iconUnique Document ID: c849c7c8b24033c486821723a60e388b29f9767e
Timestamp Audit
August 30, 2024 6:06 pm EDTRequired Amateur Fighter Registration Uploaded by Jeff Salisbury - [email protected] IP 73.135.67.211
September 9, 2024 5:56 pm EDTRonnie Rodriguez - [email protected] added by Jeff Salisbury - [email protected] as a CC'd Recipient Ip: 70.110.28.18
September 9, 2024 5:56 pm EDTRyan MacDonald - [email protected] added by Jeff Salisbury - [email protected] as a CC'd Recipient Ip: 70.110.28.18
September 9, 2024 5:56 pm EDTTCB Match Maker - [email protected] added by Jeff Salisbury - [email protected] as a CC'd Recipient Ip: 70.110.28.18
September 14, 2024 12:20 pm EDTRonnie Rodriguez - [email protected] added by Jeff Salisbury - [email protected] as a CC'd Recipient Ip: 70.110.28.18
September 14, 2024 12:20 pm EDTRyan MacDonald - [email protected] added by Jeff Salisbury - [email protected] as a CC'd Recipient Ip: 70.110.28.18
September 14, 2024 12:20 pm EDTTCB Match Maker - [email protected] added by Jeff Salisbury - [email protected] as a CC'd Recipient Ip: 70.110.28.18
September 17, 2024 3:51 pm EDTRonnie Rodriguez - [email protected] added by Jeff Salisbury - [email protected] as a CC'd Recipient Ip: 70.110.28.18
September 17, 2024 3:51 pm EDTRyan MacDonald - [email protected] added by Jeff Salisbury - [email protected] as a CC'd Recipient Ip: 70.110.28.18
September 17, 2024 3:51 pm EDTTCB Match Maker - [email protected] added by Jeff Salisbury - [email protected] as a CC'd Recipient Ip: 70.110.28.18
September 17, 2024 3:51 pm EDTJerome Antonio - [email protected] added by Jeff Salisbury - [email protected] as a CC'd Recipient Ip: 70.110.28.18
November 15, 2024 7:22 pm EDTRonnie Rodriguez - [email protected] added by Jeff Salisbury - [email protected] as a CC'd Recipient Ip: 73.133.25.229
November 15, 2024 7:22 pm EDTRyan MacDonald - [email protected] added by Jeff Salisbury - [email protected] as a CC'd Recipient Ip: 73.133.25.229
November 15, 2024 7:22 pm EDTTCB Match Maker - [email protected] added by Jeff Salisbury - [email protected] as a CC'd Recipient Ip: 73.133.25.229
November 15, 2024 7:22 pm EDTJerome Antonio - [email protected] added by Jeff Salisbury - [email protected] as a CC'd Recipient Ip: 73.133.25.229
November 17, 2024 7:59 pm EDTRonnie Rodriguez - [email protected] added by Jeff Salisbury - [email protected] as a CC'd Recipient Ip: 70.110.28.18
November 17, 2024 7:59 pm EDTRyan MacDonald - [email protected] added by Jeff Salisbury - [email protected] as a CC'd Recipient Ip: 70.110.28.18
November 17, 2024 7:59 pm EDTMatch Making Team - [email protected] added by Jeff Salisbury - [email protected] as a CC'd Recipient Ip: 70.110.28.18
November 17, 2024 7:59 pm EDTJerome Antonio - [email protected] added by Jeff Salisbury - [email protected] as a CC'd Recipient Ip: 70.110.28.18
November 17, 2024 7:59 pm EDTDee Dean - [email protected] added by Jeff Salisbury - [email protected] as a CC'd Recipient Ip: 70.110.28.18
November 19, 2024 1:57 pm EDTRonnie Rodriguez - [email protected] added by Jeff Salisbury - [email protected] as a CC'd Recipient Ip: 70.110.28.18
November 19, 2024 1:58 pm EDTRyan MacDonald - [email protected] added by Jeff Salisbury - [email protected] as a CC'd Recipient Ip: 70.110.28.18
November 19, 2024 1:58 pm EDTMatch Making Team - [email protected] added by Jeff Salisbury - [email protected] as a CC'd Recipient Ip: 70.110.28.18
November 19, 2024 1:58 pm EDTJerome Antonio - [email protected] added by Jeff Salisbury - [email protected] as a CC'd Recipient Ip: 70.110.28.18
November 19, 2024 1:58 pm EDTDee Dean - [email protected] added by Jeff Salisbury - [email protected] as a CC'd Recipient Ip: 70.110.28.18
December 17, 2024 10:37 pm EDTRonnie Rodriguez - [email protected] added by Jeff Salisbury - [email protected] as a CC'd Recipient Ip: 73.133.25.229
December 17, 2024 10:37 pm EDTMatch Making Team - [email protected] added by Jeff Salisbury - [email protected] as a CC'd Recipient Ip: 73.133.25.229
December 17, 2024 10:37 pm EDTJerome Antonio - [email protected] added by Jeff Salisbury - [email protected] as a CC'd Recipient Ip: 73.133.25.229
December 17, 2024 10:37 pm EDTDee Dean - [email protected] added by Jeff Salisbury - [email protected] as a CC'd Recipient Ip: 73.133.25.229
March 21, 2025 11:31 am EDTRonnie Rodriguez - [email protected] added by Jeff Salisbury - [email protected] as a CC'd Recipient Ip: 73.135.67.211
March 21, 2025 11:31 am EDTMatch Making Team - [email protected] added by Jeff Salisbury - [email protected] as a CC'd Recipient Ip: 73.135.67.211
March 21, 2025 11:32 am EDTJerome Antonio - [email protected] added by Jeff Salisbury - [email protected] as a CC'd Recipient Ip: 73.135.67.211
March 21, 2025 11:32 am EDTDee Dean - [email protected] added by Jeff Salisbury - [email protected] as a CC'd Recipient Ip: 73.135.67.211
March 21, 2025 11:33 am EDTRonnie Rodriguez - [email protected] added by Jeff Salisbury - [email protected] as a CC'd Recipient Ip: 73.135.67.211
March 21, 2025 11:33 am EDTMatch Making Team - [email protected] added by Jeff Salisbury - [email protected] as a CC'd Recipient Ip: 73.135.67.211
March 21, 2025 11:33 am EDTExecutive Assistant - [email protected] added by Jeff Salisbury - [email protected] as a CC'd Recipient Ip: 73.135.67.211
March 21, 2025 11:33 am EDTAdmin Assistant - [email protected] added by Jeff Salisbury - [email protected] as a CC'd Recipient Ip: 73.135.67.211
March 28, 2025 12:52 pm EDTRonnie Rodriguez - [email protected] added by Jeff Salisbury - [email protected] as a CC'd Recipient Ip: 73.135.67.211
March 28, 2025 12:52 pm EDTMatch Making Team - [email protected] added by Jeff Salisbury - [email protected] as a CC'd Recipient Ip: 73.135.67.211
March 28, 2025 12:52 pm EDTExecutive Assistant - [email protected] added by Jeff Salisbury - [email protected] as a CC'd Recipient Ip: 73.135.67.211
March 28, 2025 12:52 pm EDTAdmin Assistant - [email protected] added by Jeff Salisbury - [email protected] as a CC'd Recipient Ip: 73.135.67.211
May 30, 2025 8:08 pm EDTRonnie Rodriguez - [email protected] added by Jeff Salisbury - [email protected] as a CC'd Recipient Ip: 73.135.67.211
May 30, 2025 8:08 pm EDTMatch Making Team - [email protected] added by Jeff Salisbury - [email protected] as a CC'd Recipient Ip: 73.135.67.211
May 30, 2025 8:08 pm EDTExecutive Assistant - [email protected] added by Jeff Salisbury - [email protected] as a CC'd Recipient Ip: 73.135.67.211
May 30, 2025 8:08 pm EDTAdmin Assistant - [email protected] added by Jeff Salisbury - [email protected] as a CC'd Recipient Ip: 73.135.67.211
May 30, 2025 9:02 pm EDTRonnie Rodriguez - [email protected] added by Jeff Salisbury - [email protected] as a CC'd Recipient Ip: 73.135.67.211
May 30, 2025 9:02 pm EDTMatch Making Team - [email protected] added by Jeff Salisbury - [email protected] as a CC'd Recipient Ip: 73.135.67.211
May 30, 2025 9:02 pm EDTExecutive Assistant - [email protected] added by Jeff Salisbury - [email protected] as a CC'd Recipient Ip: 73.135.67.211
May 30, 2025 9:02 pm EDTAdmin Assistant - [email protected] added by Jeff Salisbury - [email protected] as a CC'd Recipient Ip: 73.135.67.211
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