SWORN STATEMENT

Poco Loco Race

I, …………………………………………………………………………………,

Currently residing at…………………………………………………………………………………………

Do hereby depose and state that:

• I have participated in the following ultra (endurance) races:

…………………………………………………………………………………….…………………………………………………

• (to be filled if no ultra-endurance experiences) I have participated in the following sports events:

…………………………………………………………………………………….…………………………………………………………………………………….…………………………………………………………………………………….

• I haven’t any cardiac or cardiovascular history and/or asthma or I have a medical certificate of my doctor who allows me to practice sports
• I understand and accept fully the extreme risks of the Poco Loco race ……………………. as indicated in the race agreement signed when I registered

Signed this day of_______, ___________,

Day Month Year

Signature