Athletes Full Family/Last Name as stated in Passport:

Athletes Full First/Given Name as stated in Passport:

Nationality/Country:
—Please choose an option—Select CountryUSACanadaUKAustralia

Attach Athlete Passport size photo:

Date of Birth:

Legal Gender as in Passport:
[radio* legal-gender use_label_element "Male" "Female"]

Eligibility Group:
II1 - Intellectual Disability - NationalII1 - Intellectual Disability - InternationalII2 - Significant Additional ImpairmentII3 - Autism

Sports in which the Athlete will compete:

Athlete Address:

Phone Number:

Email Address:

If the Athlete is under 18 years of age, or without legal competency to sign:

Parent/Guardian Name:

Relationship:

Parent/Guardian Address:

Phone Number:

Email Address:

Athlete Social Media Pages:

Declarations & Permissions - This Page to be completed by the athlete's representative

ATHLETE DECLARATION (All athletes must complete, by ✔ each box and signing below)
a) I understand and comply with eligibility criteria to complete as an athlete with intellectual Impairment.
b) I confirm that I shall comply with all Virtus policies and procedures including, but not limited to all of the provisions of the Anti-Doping Policy, all amendments to the Anti-Doping Rules and all International Standards as issued by the World Anti-Doping Agency and permanently published on its website. I acknowledge that National Federations, Virtus and National Anti-Doping Organizations have jurisdiction to impose sanctions as provided in Anti-Doping Rules.
c) I give Virtus permission to hold information electronically and to use information in accordance with the Privacy Policy. I agree that in order to maintain the principles of fair eligibility and classification, Virtus may retain relevant and essential information indefinitely.
d) I understand and agree to uphold the principles of the Virtus Code of Ethics and the spirit of fair play.
e) I agree to Virtus using photographs and images of me for the purposes of publicity in print, electronic and other media, and can withdraw this consent at any time by writing to the secretariat.
f) I agree that data I have provided can be used for research purposes, as set out under the Virtus research code, and this data will not identify me individually and be managed under the Virtus Privacy Policy.
g) I give Virtus permission to use this information to decide whether I am a person with intellectual impairment for eligibility and sports classification and to share this information with relevant organizations including, but not limited to, the IPC and International Federations.
h) I understand the risks associated with competition and that I am responsible for my actions at all times.
i) As far as I know, all the information in my application is true and accurate.
j) I understand what the information in this form is being used for or have had this explained to me.

Athletes Signature or Identifying Mark:

I wish to join the Virtus email list for newsletters

PARENT OR LEGAL GUARDIAN (if the athlete is under 18, or without legal capacity to give consent)

By signing this declaration I am saying that the athlete named above is under 18 years, or without legal capacity to sign on their own behalf. I understand the above declaration and have the legal right to sign on behalf of this person.

Signature+Name:

Relationship to Athlete:

I wish to join the Virtus email list for newsletters