Fillable SOUTH DAKOTA ATHLETIC COMMISSION REGISTRATION APPLICATION (South Dakota DLR)

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SOUTH DAKOTA ATHLETIC COMMISSION REGISTRATION APPLICATION (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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CONTESTANT REGISTRATION 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
BOXER | KICKBOXER | MIXED MARTIAL ARTIST
REGISTRATION APPLICATION
INSTRUCTIONS
1. A completed Application and $50 fee must be submitted with application. (Cash or check only)
2. Acceptable photo identification must accompany the Application.
3. 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.
4. Verification of a physical within the previous12 months from a licensed physician must be submitted with application.
5. Verification of a dilated eye exam within the previous 12 months from a licensed optometrist or ophthalmologist must be
submitted with application.
6. Proof the applicant has been tested in the previous 6 months and is negative for HIV, Hepatitis B and Hepatitis C must be
submitted with application.
7. Verification of a Federal Identification Number.
Please provide answers to the following questions and appropriate follow up information or documentation.
1. Are you currently licensed or registered to compete in any other jurisdictions (state or tribal)? □ Yes □ No
If yes, list state(s) and/or jurisdiction(s) _______________________________________________________
2. Have you ever been denied a license or registration to compete by any other jurisdiction (state or tribal)? □ Yes □ No
If yes, list state(s) and/or jurisdiction(s) ________________________________________________________
3. Do you have any type of medical insurance? □ Yes □ No
If yes, please provide the Carrier name and telephone number_____________________
o ATHLETIC COMMISSION
Legal Name
Professional/Stage Name
Address
City
State
Zip Code
Telephone Number
Date of Birth
Social Security Number
Federal ID Number
Height
Weight
Weight/Division
Eye Color
Hair Color
Distinguishing Marks
Name of Emergency Contact
Telephone Number of Emergency Contact
Name of Trainer
Name of Club where you train
Overall Amateur Record
Location of Last Fight
Result of Last Fight
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 _____________
ATHLETIC COMMISSION CONTESTANT REGISTRATION 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 (South Dakota DLR)

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Completed 21 August 2020

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