Pilot Registration Form

Pilot Registration Form for TeamsCYBATHLON Wheelchair Series Japan 20191Team1.1

Team name(same as in Series Registration Form for Teams)

The pilot shall have consulted a certified medical doctor who shall have confirmed that there are no objections
to participation of the pilot at the CYBATHLON races from a medical standpoint. The medical doctor shall befamiliar with the potential risk of injuries that can occur in parathletic activities such as those performed at theCYBATHLON Wheelchair Series Japan 2019 as well as the physiological stress inherent in competitive situations
such as CYBATHLON races. In case of medical doubt the medical doctor shall conduct specific medical screening(e.g. cardiovascular disease screening) prior to the pilot’s participation in the CYBATHLON Wheelchair Series Japan
2019.
Please provide the following general information for each pilot (use a separate Pilot Registration Form to register
another pilot):
2

Pilot general information

2.1

FAMILY NAME

2.2

First name, middle name(s)2.3Institution/Company

2.4

Street, Number

2.5

Postal code

2.6

City

2.7

Country

2.8

Citizenship2.9

Email address

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2.10

Phone office

2.11

Phone mobile

2.12

Sex

2.13

Year of birth (dd/mm/yyyy)

2.14

Email address may bedisclosed for event related
media purposes, sponsors, orpublic□ yes, I allow disclosure

Personal data may bedisclosed for event related
purposes (e.g. programme
leaflet, website, team
introductionin the arena)yes, I allow disclosure of□ age

2.15□ female□ male□ other□ no, I do not allow disclosure□ details about lesion/injury/ impairment□ time since injury
no, I do not allow disclosure of□ age□ details about lesion/injury/ impairment□ time since injury

Please provide the following information for the discipline in which the pilot is participating. Please find theinclusion criteria here: https://www.ethz.ch/content/dam/ethz/special-interest/conference-websites-dam/cybathlon-dam/documents/Team_Registration_03_18/CYBATHLON_Races_and_Rules.pdf

WHL

Powered Wheelchair Race

WHL.1

Kind of diagnosis (e.g. SCI,Stroke, MS, ALS)
Description (e.g. Hemi-/Para-/ Tetraplegia; Lesion
height, complete,incomplete, etc.)WHL.2

AIS (if available)

WHL.3

Other scores (if available)

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□A□B

□C□D

□ unknown

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3

Further required information

3.1

Time of lesion/injury (mm/yyyy)

3.2

Other lesion / injury / impairment

3.3

Able to stabilise trunk

□ yes

□ no

Able to stabilise neck and head

□ yes

□ no

Able to control arms and hands

□ yes

□ no

Wheelchair user

□ manual

3.4

3.5□ powered□ no

Postural support used

□ pelvis□ torso □ head □ noFrequency of use□ rarely□ occasionally□ frequently□ crutches□ caneUse of other assistive technology□ yes□ noKind of assistive technology□ walker

Other assistive technology
3.6

Technical assistance for respiration

□ yes

□ no

Kind of assistance for respiration□ pacemaker□ ventilator

Other assistance for respiration
3.7

Implanted medication pumps or
pacemakers of any kind (e.g. cardiac)

□ yes

□ no

□ yes

□ no

If yes, please describe

3.8

Participated in similar events
If yes, describe (type, how often)

Please note that a written confirmation in English signed by a medical doctor is required stating that the pilot is fit
for participation in CYBATHLON races.

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At any point on the day of CYBATHLON Wheelchair Series Japan 2019, the pilots can be tested on their abilities.
If their abilities do not meet the inclusion criteria the pilot will be disqualified. Please find the inclusion criteria
in the Race Task Description CYBATHLON Wheelchair Series 2019.
Now and therefore
I, the undersigned pilot in the CYBATHLON Wheelchair Series Japan 2019 and during the team preparation stage
acknowledge herewith that my participation to the event involves risks inherent in such event with equipment
prototypes. I will have at least one technical testing session with the technology provider. I assume all the risks of theCYBATHLON Wheelchair Series Japan 2019 and team preparation stage, including health and personal safety risks.
Furthermore, I am obligated to follow the instructions delivered by the technology provider and/or the CYBATHLON
Series organisers.
In any case, insurance is the team officials’ own responsibility. The team leader and pilot will be asked on---site to signa registration sheet, including insurance statements. If that document is signed, the CYBATHLON Series organisers
must and will assume that adequate insurance coverage has been obtained as requested.
For the avoidance of doubt, participation in the CYBATHLON 2020 is governed by Swiss law.
Therefore, in consideration of the risks, I, the undersigned, intending to be legally bound, consent to the assumption ofsuch risks.
Please send both an electronic AND a printed, signed (wet ink) and scanned copy by email to the CYBATHLON
Series organiser (teams@cybathlon.com).

 DatePlaceName and signature of the pilot

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