THE 43rd OITA INTERNATIONAL WHEELCHAIR MARATHON (Nov.17, 2024)
ENTRY & MEDICAL IDENTITY FORM
(ALL ATHLETES & ACCOMPANYING PERSONS SHALL SUBMIT THIS FORM)※An entry fee will not be charged for international participants.

PERSONAL INFORMATIONNAME ( as in your passport )first

APPLICATION AS:/middleDATE OF BIRTH/month//AGE/day/□ ATHLETE

lastSEX□ ACCOMPANYING PERSON□MALE□FEMALE

PHOTO

TO:
Wheelchair user (escort):year□YES*You must be 14 yrs. or older as of Nov. 17, 2024

ADDRESS ( including apartment no., suite, floor )□ NO

Please clip on
your photo

NEED DOCUMENT FOR VISA
□YES

□NO

NATIONALITY:PHONEFAXEMAILOCCUPATIONFAREWELL PARTY (ALL FREE): □Attend □Not Attend

RACE INFORMATIONENTRY DIVISION :□MARATHONPARTICIPATION IN OITA :□First Time

□HALF MARATHON□Finished□Not Finished

NAME OF COM./ ASSO. YOU BELONG TO AS ATHLETE:WORLD PARA ATHLETICS ATHLETE REGISTRATION NUMBER IN THE SDMS:＊Attach the proof of your record.

PERSONAL BEST RECORD ( marked during Sep.1, 2022 – Aug.31. 2024 )TIME::hrs.

:

AT:

mins.

ON:

sec.

name of race/month/

/
day/

year

TRAVEL INFORMATIONINTERNATIONAL FLIGHT/
month/

/
day/:
hrs

:

mins

< ARRIVAL IN JAPAN >port of boarding/
month/

arrival airport/day/flight no.

:
hrs

:

mins

<DEPARTURE FROM JAPAN>
port of landing

departure airport

TYPE OF ACCOMMODATION ( Subject to Room Availability ): □SINGLE

flight no.

□TWIN ( Roommate:)※Please send us your travel information by August 31st.
※Please note that the cancelation fees of the hotel and domestic flight will be charged if you change
your flight.
MEASUREMENTS OF YOUR DAILY WHEELCHAIR AND RACING CHAIR ( RACING CHAIR BOX)DAILY WHEELCHAIR (cm ):Height□Collapsible □Not Collapsible Weight (kg)
RACING CHAIR(cm):Height

LengthWidth

LengthWidth

HeightLengthWidth

Weight (kg)※ with the racing chair in the box

Weight (kg)
RACING CHAIR BOX (cm):CLASSIFICATION STATUS INFORMATION
□T51

□T52

□T53/54

□T33

□T34

＊ If available, please attach your International classification certificate issued by WPA

Medical Diagnosis□SPINAL CORD INJURY
MOTOR LEVEL□C□TH□COMPLETE□POLIOMYELITIS□AMPUTATION □SA/K□DYSFUNCTION WITH C.P□LES AUTRES□OTHERS

SITTING BALANCE□L□IMCOMPLETE

□SB/K

□DA/K

□+

□-

□DB/K

NumberCard
7

ACCEPTANCE OF RISK AND RELEASE OF CLAIMS
I and my accompanying person hereby agree to obey the rules, regulations and directions of Oita International
Wheelchair Marathon. I understand that there is potential risk of serious injury or death by racing in this event. I
understand the possibility of danger by falling during the race, influence of weather, contact with other athletes, traffic
conditions, etc., and I will take responsibility for myself. In consideration of your accepting this entry, I hereby formyself and accompanying person, executors and administrators waive and release any and all rights and claims fordamages I may have against the Oita International Wheelchair Marathon Organizing Committee, governors, officers,or the sponsors for any and all injuries suffered by me in said event. I attest and certify that I am physically fit andhave sufficiently trained for competition in this event. I agree not to alter my running number in any way in thisevent. I and my accompanying person grant to the Oita International Wheelchair Marathon Organizing Committee
the exclusive right to the free use of name, voice, and/or photograph in any broadcast, telecast, advertising,promotion or other account of this event.
SIGNATURE/

DATE:
month/

day/

2024

/

year

Mail to: OITA Sports Association for the Disabled, C/O 3-1-1 Otemachi, Oita City, 870-8501 JAPAN postmarked August 31, 2024