ATHLETIC COMMISSION CONTESTANT REGISTRATION REV 03/2019
MEDICAL AND INFORMATION RELEASE AUTHORIZATION
I authorize the South Dakota Athletic Commission to release any medical information or other personal information
maintained by the South Dakota Athletic Commission as a condition of my registration as a boxer, kickboxer, or mixed
martial artists, or any medical or personal information acquired as result of competing in a boxing, kickboxing or mixed
martial arts competition overseen by the South Dakota Athletic Commission to other state licensing bodies, insurance
companies providing insurance coverage for a boxing, kickboxing, or mixed martial arts competition overseen by the
South Dakota Athletic Commission, law enforcement entities, or a physician assigned to provide medical services at a
boxing, kickboxing or mixed martial arts competition overseen by the South Dakota Athletic Commission.
I agree that a copy of this authorization shall be as valid as an original. I further agree that this authorization is valid for
a period of one year from the date of my signature on this document.
__________________________________________________________ __________________________________________________ ____/____/_______
Name of Applicant (Please Print) Applicant’s Signature Date
My signature below, I verify, under penalty of perjury, that I am the person completing this application and that all
information submitted is true and correct to the best of my knowledge and that false or incorrect information,
omissions, inaccuracies or failures to make full disclosure may result in the cancellation or denial of a registration
issued pursuant to this application and may be subject to civil and criminal proceedings. Furthermore, I acknowledge
that i have read and understand that I am responsible for compliance with SDCL chapter 42-12 and ARSD article 20:81
in the role(s) I am seeking registration for and am aware of all said responsibilities and requirements and agree to abide
by all said responsibilities and requirements. I further agree to hold the South Dakota athletic commission harmless for
any injury or death that may occur as a result of participating in any competition.
________________________________________________________________ ____/____/_______
Applicant’s Signature Date
For Commission Use Only Fee ____________ Physical ____________
Eye Exam ____________ Blood Results ____________
Waiver ____________ Federal ID _____________