2012 West Virginia Association USA Track & Field

TRACK & FIELD CHAMPIONSHIP

OFFICIAL INDIVIDUAL ENTRY FORM

June 16, 2012

Paul J. Gilmer, Jr.

Capital City Striders, Inc.

P O Box 1243

Charleston, WV 25326-1243

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

Fax 304-343-0129 (pjgilmer@aol.com)

NAME: ____________________________________________________________________

(Last) (First) (Middle Initial)

Street Address: ___________________________________________________________________________

City: ____________________________________ State: ________ Zip Code: ____________________

Phone: __________________________________E-Mail_ __________________________________

Circle One: Male Female USA T & F

Birth date: _______/_______/______: 2012 Membership Number ___________________

Track Club: _________________________ Phone: ____________________________

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 USA T&F , USATF and Local Sponsors, for any and all damages which may be sustained and suffered by me in conjunction with my association in Track & Field Meet. I attest and certify that I am physically fit to participate in this event.

___________________________________ ____________________________________

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