2006 West Virginia Amateur & Youth

TRACK & FIELD CHAMPIONSHIP

OFFICIAL INDIVIDUAL ENTRY FORM

                                                                        June 17, 2006

            Paul J. Gilmer, Jr.

                                                            Capital City Striders, Inc.

                                                            P O Box 1243

                                                            Charleston, WV 25326-1243

                                                            304/343-0128 (Day)    304/389-1982 (Night)

 

ENTRIES MUST BE RECEIVED BY FRIDAY, JUNE 16, 2006

This form may be reproduced for additional entries

18 & under Entry Fee $5.00_____               19 & up Entry Fee     $ 5.00______      AAUSPORTS.ORG

USATF Membership $12.00______             USATF Membership $15.00______

AAU Membership     $12.00______

TOTAL                                                                  TOTAL                                                USATF.ORG

                        Check, Cash, Certified Check, or Money Order will be accepted

 

NAME:   ____________________________________________________________________

                                (Last)                                                      (First)                                                                (Middle Initial)

 

Street Address: ___________________________________________________________________________

 

City: ____________________________________ State: ________ Zip Code: ____________________

 

Phone: __________________________________E-Mail_ __________________________________

 

Circle One:    Male           Female                AAU and/or USATF

 

Birth date:      _______/_______/______     2006 Membership Number                                      

 

 Track Club: _________________________ Phone: ____________________________

 

Appropriate Age Division (Circle One):            Primary (1998 or after)           

            Athletes who are still eighteen                 Sub Bantam (1997)     Bantam (1996)     

            (18) through the last day                         Sub Midget (1995)       Midget (1994)                            

            Of National Competition are                    Youth (1992-1993)        Intermediate (1990-1991)                      

            Eligible (July 30, 2006)                           Young Women/Men (1988-1989)

                                                            OPEN (after 7/30/1987- 1977)

                                                                        Masters (1978 or before)

EVENT ENTERED                                                                 PERFORMANCE MARK

1.         _________________________________            ___________________________

2.         _________________________________            ___________________________

3.         _________________________________            ___________________________

4.         _________________________________            ___________________________

 

I do hereby for myself, my heirs, and executors, assign, waive, and release any and all rights and claims for damages which I may hereafter accrue to me against Laidley Field, National AAU House & Youth Sports, WV AAU District , USATF and Local Sponsors, for any and all damages which may be sustained and suffered by me in conjunction with my association in Region VI Track & Field Meet.  I attest and certify that I am physically fit to participate in this event.

 

___________________________________  ____________________________________

(Athlete’s Signature)                                                                        (Parent or Guardian Signature)