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SOUTH DAKOTA ATHLETIC COMMISSION REGISTRATION APPLICATION FOR SECONDS (South Dakota DLR)

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South Dakota Department of Labor & Regulation (DLRA) aim to promote economic opportunity and financial security in the South Dakota. They support individuals and businesses through expert services, employment solutions and business practices.

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ATHLETIC COMMISSION REGISTRATION APPLICATION FOR SECONDS REV 03/2019
SOUTH DAKOTA DEPARTMENT OF LABOR AND REGULATION
SOUTH DAKOTA ATHLETIC COMMISSION
1351 N. Harrison Ave., Pierre, SD 57501
Tel: 605.224.1721 Fax: 866.425.3032 dlr.sd.gov/athleticcommission
REGISTRATION APPLICATION FOR SECONDS
INSTRUCTIONS
1. A completed Application and $25 fee must be submitted with application. (Cash or check only)
2. A Completed Release and Waiver of Liability, Assumption of the Risk and Indemnity Agreement and Consent to Medical
Treatment by the Applicant must be submitted with the Application.
Competition Type(s):
□ Boxing Competitions □ Kickboxing Competitions □ Mixed Martial Arts Competitions
Name
Date of Birth
Street Address or PO Box
E-mail Address
City
State
Zip Code
Telephone Number
Licenses and Registrations in Other Jurisdictions
Other States or Jurisdictions where licensed or registered to perform similar duties:
Have you been disciplined, fined or had a license/ registration revoked, suspended or disciplined by any athletic commission or
similar entity or been denied a license or registration for any reason by any athletic commission or similar entity? (If yes, please
provide an explanation.)
□ Yes □ No
BY 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, OMMISSIONS, 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.
_________________________________________________ _____/______/______
Signature of Applicant Date
FOR COMMISSION USE ONLY
Fee Received ________________________ Check: ______ Cash: _____ Date _____________________
Waiver Received _____________________ Date __________________
ATHLETIC COMMISSION REGISTRATION APPLICATION FOR SECONDS REV 03/2019
RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF THE RISK AND INDEMNITY AGREEMENT AND
CONSENT TO MEDICAL TREATMENT
By my signature below, I acknowledge that I am aware of, appreciate the character of, and voluntarily assume
the risks involved in participating in
By my signature below, on behalf of myself, my heirs, next of kin, successors in interest, assigns, personal
representatives, and agents, I hereby:
1. Waive any claim or cause of action against and release from liability the State of South Dakota, its
officers, employees, and agents for any liability for injuries to my person or property resulting from my
participation in the activity listed above;
2. Agree to indemnify and hold harmless the State of South Dakota, its officers, employees, and agents
for any claims, causes of action, or liability to any other person arising from my participation in the activity
listed above; and
3. Consent to receive any medical treatment deemed advisable during my participation in the activity
listed above.
I HAVE READ THIS RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF THE RISK AND INDEMNITY
AGREEMENT AND CONSENT TO MEDICAL TREATMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I
HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND HAVE SIGNED IT FREELY AND VOLUNTARILY
WITHOUT ANY INDUCEMENT, ASSURANCE, OR GUARANTEE BEING MADE TO ME AND INTEND MY SIGNATURE
TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST EXTENT ALLOWED BY
LAW.
Name ______________________________________________ Date of Birth _____/_____/_______
Address_____________________________________________________________________________
Signature ____________________________________________________ Date_____/_____/_______
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SOUTH DAKOTA ATHLETIC COMMISSION REGISTRATION APPLICATION FOR SECONDS (South Dakota DLR)

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Completed 21 August 2020

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