Processing No. ________ Age
Division: ______________ Check
one: Male ____ Female
______
Athlete or
Club Name: _ ________ Coaches
must bring each athlete’s Coach:
__ ________________________
Documents to verify age
Address: ____________ Photo
Copies are acceptable Club
Name: _______________________
List athlete’s name, Division, and
best time or performance to date for each event. Entry fee is $3.00 per event and $12.00 per
relay team if received by June 11th
Late or same day entry $5.00 per
event. Indicate total per athlete in the
fee column and compute the total at the bottom of each entry form. Enter Males & Females on separate
forms and use the codes below to indicate age division. All divisions must be based on the athlete’s
age as of December 31, 2009.
Entry fees may be paid by check or money order payable to Capital
City Striders, Inc. Forms must be received by June 11th.
Mail to Capital City Striders, Inc.,
|
Athlete’s Name Last, First |
Athlete’s Birth-date |
Dashes |
Runs |
Hurdles |
Relays |
Field Events |
Race Walk |
Steeple- chase |
Fee |
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|
50 |
100 |
200 |
400 |
800 |
1500 |
3000 |
5000 |
80/ 100 |
110 |
200 400 |
4x 100 |
|
4x 400 |
4x 800 |
Jav |
HJ |
LJ |
TJ |
SP |
PV |
Disc |
3000 1500 |
2000/ 3000 |
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10. |
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Athletes who participate in this
competition may be subject to formal drug testing in accordance with USA
Track & Field Regulation 10 and IAAF Rule 55. Athletes found positive for banned
substances or who refuse to be tested will be disqualified from this event
and will lose eligibility for future competitions. Some over-the-counter medications
contain banned substances. For information on drugs and drug
testing, call the USOC hot line at 800/233-0393. |
# events_____ |
X
3.00 + |
$ |
|||
|
# Relays_____ |
X 12.00 + |
$ |
||||
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Total: |
$ |
||||
|
4-6 7-8 9-10 11-12 13-14 15-16 17-18 19-29 30-39 40-49 50-59 60+ |
Sub-Sub-Bantam Sub-Bantam Bantam Midget Youth Intermediate Young Open Sub-Master Master Master/Master Grand Master |
SSB SB B M YT I Y O SM MA MM GM |
In consideration of my being
accepted, I waive all rights and claims for myself and my heirs, executors,
or administrators, for any damages, which may occur to me as a result of this
competition. Athlete / Team Official / Coach: _
_________________________ Date: ____________ Parent/Guardian Signature: ____
__________________ Date________ (For athletes under age 18) |
Capitol City Striders, Inc. |
||