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WICHITA TRIBE SPORTS COMMISSION

Pregnancy Test Consent Form

The Wichita Tribe Sports Commission (WTSC) requires all female athletes to take a urine pregnancy test before being allowed to compete in any combat sport sanctioned or regulated by The WTSC. To be eligible to compete, the result must be “negative” meaning the fighter is not pregnant. This routine test is performed on all female contestants of childbearing age, even if you are not sexually active. If there is a chance you could be pregnant it is imperative that you let the attending physician or athletic commission know. I understand that a positive pregnancy test result will prevent me competing in any event sanctioned by The WTSC until further notice.

• I consent to having a pregnancy test administered before the event.

______________________________________ ____________________

Signature Date

• I decline taking a pregnancy test. I understand by doing so that this may put me in violation of my signed agreement or contract with the promoter.

______________________________________ ____________________

Signature Date

Official Use Only

Pregnancy hCG Urine Test Administered ρ Yes ρ No

Pregnancy Test Result ρPositive ρNegative

As the appointed commission representative, I attest that all above information is correct and consistent with the results of the test that was taken in my presence.

______________________________________ ____________________

Signature Date

2014/11

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