PROVISIONAL CLASSIFICATION FORM

PARA-ATHLETES with PHYSICAL IMPAIRMENT

Classification is integral to Para- Sport as it provides the structure for fair and equitable competition.

Each Para- Sport has a different sports specific Classification System.

A ProvisionalClassification is a temporary classification that enables a Para-Athlete to enter a Para-Sport event for the first time. It places a Para-Athlete into a competition category where they compete against other athletes with a similar activity limitation resulting from impairment.

A Provisional Classification is valid for two years from time of issue or earlier if the Para-Athlete can be assessed by a classification panel for a National Classification.

PLEASE NOTE FOR SECONDARY SCHOOL STUDENTSA provisional classification is valid for the length of time the Para-Athlete is at secondary school or earlier iftheyreceive a National Classification.

  • ThisClassification Form needs to be completed by Para-Athleteswith a Physical Impairment.
  • Sections 1 and 3 may be completed by the athlete.
  • Section 2MUST be completed by the athlete’s medical physician.
  • Athletes with a Visual Impairment must complete a Visual Impairment Provisional Classification Form (available on the PNZ website).
  • Athletes with an Intellectual Impairment must complete the Intellectual Impairment Provisional Classification Form(available on the PNZ website).

Forms are to be emailed to the PNZ Classification Manager NO LATER than four weeks before the eventat

Provisional Classification certification will be sent via email.

SECTION 1 – ATHLETE INFORMATION

(Can be completed by the athlete, or their representative)

Last Name:

First Name:

Address:

Suburb:

City:Postcode:

Phone (Hm):( )Mobile:( )

Email:

MaleFemaleDate of Birth

SECTION 2 – MEDICAL INFORMATION

(MUST be completed by athlete’s medical physician)

State Medical Diagnosis(Health Condition) and Resulting Loss of Function(Impairment):

Is the Health Condition:(tick)

  • Permanent:
  • Non Permanent
  • Congenital
  •  Acquired Date:

Impairment Type/s: (tick)

  • Limb Loss or Deficiency
  • Limb/s :
  • Level of amputation:
  • Impaired Muscle Power:
  • If spinal cord injury (SCI)
  • Level of lesion:
  • Complete or incomplete:
  •  Impaired Joint Range of Movement
  • Joint/s affected::
  • Neurological:
  •  Hemiplegia  Diplegia  Quadraplegia
  •  Hypertonia
  •  Ataxia
  •  Athetosis
  • Short Stature
  • Height:
  • Leg length Difference
  • Length Difference:

Additional recent and relevant medical documentation MUST be enclosed if:

  • Athlete has a medical diagnosis and/or impairment that presents with no clear signs and symptoms.
  • Athlete has acomplex or rare health condition or multiple impairments.(Documentation could include photos of impairment).
  • Athlete has aspinal cord injury (Recent ASIA scale results to be enclosed).
  • Athlete has a neurological impairments of ataxia, athetosis or hypertonia (A Modified Ashworth Scale score to be completed by a physician or physiotherapist and enclosed)
  • Athlete has aloss of muscle power or range of movement.(Muscle power test or range of movement test scoreto be completed by a physician or physiotherapist and enclosed).

Medication(Regular)

Medical Declaration

(To be signed by athlete’s medical physician)

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PNZ Provisional Classification Form

SECTION 2 – SPORTING HISTORY

(Can be completed by athlete)

What Sport/s do you require a provisional classification in?

  • Are you able to walk?  yes no
  • Do you use crutches or a mobility aid?  yes no Type:
  • Are you a full time wheelchair user?  yes no
  • Years involved in the sport:
  • Do you train with a coach?
  • Number of training sessions a week:
  • Number of competitions in the last 12 months:

Do you compete?

  •  Seated (wheelchair user)
  •  Standing (Ambulant)

Athlete Declaration

I declare the information submitted on this form to be a true and accurate reflection of my sporting history.

I understand that failure to give accurate information may result in me receiving an incorrect classification.

I understand that I will receive a provisional classification according to the information that I submit to Paralympics New Zealand on this form. I understand that information from this classification form will be held by Paralympics New Zealand (PNZ)whomay share this information with other Regional and National Bodies that are involved in your development in sport.

I agree to having my photo taken and/or a video taken to support information for classification purposes.

Signature of AthleteDate

(or guardian if under 18)

PNZ Provisional Classification Form

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