ENTRY FORM

2009 USATF 1st ANNUAL NORTHWEST S.O.A.K. CHAMPIONSHIPS!

CHALLENGED ATHLETES MEET

(WHEEL CHAIR, CERBAL PALSY, LEARNING DISABILITY etc.)

Send entries and make money orders or checks to RMFP at 229 Grand Ave Billings, Montana 59101

Last Name ________________________ First _________________________

Address ________________________________________________________

City ______________________ State ____________ Zip _______________

Telephone (

) ______________ Email (opt.) _________________________

USATF Association ______________________ .

2009 USATF Member No. ___/___/___/___/___/___/___/___/___/___/ (Required)

50m - 1st grade to 6th grade

Shot Put - 4th grade to High School

100m - All age groups

800m Wheel chair - High School,

Long jump - All age groups

400m - All age groups.

100-Learning Disability, Cerebral Palsy, Wheel Chair, Amputee

Long Jump- Learning Disability, Amputee,

400-Learning Disability, Cerebral Palsy, Blind w/ guide

800m Wheel Chair

Shot Put – Wheel Chair, Learning Disability, Amputee

200m- Learning Disability, Cerebral Palsy, Amputee

1600m - open to all

EVENTS

1) ______________________ 3) _____________________

2) ______________________ 4) ____________________

Athletes Release: I voluntarily agree to participate in the 2009 USA Track & Field Junior Olympic Championships and knowingly assume any and all risks of loss, damage to my person or property, injury (including death), both foreseen and unforeseen, of my attendance at and participation in the 2009 USA Track & Field Junior Olympic Championships, from any cause whatsoever, including the fault or negligence of Releases (as defined below). I, for myself, my heirs, personal representatives and assigns do hereby release, waive, discharge and covenant not to sue USA Track & Field, Inc., the local USATF Association, the Local Organizing Committee, the Facility and Championship Sponsors, their respective officers, directors, employees, agents and volunteers (collectively "Releases") from all liability, loss, claims, demands, possible causes of action, court costs, settlement costs and fees, attorneys fees and any other expenses arising from any claim or lawsuit that may arise from any loss, damage or injury (including death) to me or my property resulting from or arising in connection with, or related to, my attendance at or participation in the 2009 USA Track & Field Junior Olympic Championships. In the event that I am injured, I hereby consent to the provision of necessary and appropriate emergency medical treatment.

By entering this competition, I grant USA Track & Field, Inc. a limited license to use my name, likeness, image, voice, video, athletic performance, biographical and other information, in any format whatsoever, and to distribute, broadcast and exhibit these without charge, restriction or liability, but only for the purposes of advertising or promoting the sport of Athletics. In no event, however, will such usage constitute an endorsement of any product or service without my specific written consent.

Signature - ATHLETE .

Signature - PARENT / GUARDIAN (Must be signed if athlete is under 18 years of age.)

ADA request: I am requesting an accommodation for a disability as follows:

2009 USATF MONTANA ASSOCIATION JUNIOR OLYMPIC TRACK & FIELD CHAMPIONSHIPS

Please type or print legibly

Last Name ________________________ First _________________________

Address ________________________________________________________

City ______________________ State ____________ Zip _______________

Telephone ( ) ______________Email (opt.)_________________________

Full USATF Club Name ____________________________________________

USATF Club Number ____/____/- ____/____/____/_____/

USATF Association _MONTANA___________ USATF Region ____XI_______

2009 USATF Memb. No. ___/___/___/___/___/___/___/___/___/___/ (Required)

Association Championships

Please list events in which you are going to compete. If Preliminary meets were contested, use time/mark and place. If not, use approximate time/mark for seeding purposes.

Event Time/Mark Place Event Time/Mark Place

1) ______________________ _________ ______ 3) _____________________ __________ ______

2) ______________________ _________ ______ 4) ____________________ __________ ______

Combined Events ________________________ Total Pts __________ Place _________

Regional Championships June 25 - 27 Northwest Nazarene in Nampa, Idaho

Please list events in which you are going to compete: list place and time/mark achieved at the association meet.

Event Time/Mark Place Event Time/Mark Place

1) ______________________ _________ ______ 3) _____________________ __________ ______

2) ______________________ _________ ______ 4) _____________________ __________ ______

Combined Events ________________________ Total Pts__________ Place_________

July 28 – August 2 National Championships Irwin Belk Track Greensboro,NC

Entry Fees $8.00 Indiv. Events, $32.00 Per Relay, $24.00 Heptathlon/Decathlon, $20.00 Triathlon/Pentathlon

Please list events in which you are going to compete: list place and time/mark achieved at the regional meet.

Event

Time/Mark Place

Event

Time/Mark

Place

1) ______________________ _________ ______ 3) _____________________ __________ ______

2) ______________________ _________ ______ 4) _____________________ __________ ______

Combined Events ________________________ Total Pts__________ Place________

Athlete’s Release: I voluntarily agree to participate in the 2009 USA Track & Field Junior Olympic Championships and knowingly assume any and all risks of loss, damage to my person or property, injury (including death), both foreseen and unforeseen, of my attendance at and participation in the 2009 USA Track & Field Junior Olympic Championships, from any cause whatsoever, including the fault or negligence of Releasees (as defined below). I, for myself, my heirs, personal representatives and assigns do hereby release, waive, discharge and covenant not to sue USA Track & Field, Inc., the local USATF Association, the Local Organizing Committee, the Facility and Championship Sponsors, their respective officers, directors, employees, agents and volunteers (collectively "Releasees") from all liability, loss, claims, demands, possible causes of action, court costs, settlement costs and fees, attorneys fees and any other expenses arising from any claim or lawsuit that may arise from any loss, damage or injury (including death) to me or my property resulting from or arising in connection with, or related to, my attendance at or participation in the 2009 USA Track & Field Junior Olympic Championships. In the event that I am injured, I hereby consent to the provision of necessary and appropriate emergency medical treatment.

Athletes who participate in this competition may be subject to drug testing. Visit the competition's Athlete Information page (www.usatf.org/events/2009/USATFJuniorOlympicTFChampionships) for more information..

Signature - ATHLETE

Signature - PARENT / GUARDIAN

(Must be signed if athlete is under 18 years of age.)

ADA request: I am requesting an accommodation for a disability as follows: ____________(visit www.usatf.org/about/legal/policies/ADA.asp for forms and procedures)

*Please note: All requests for accommodations must be received six weeks prior to the date of competition.

List allergies and current medications: __________________________________________________________________________________________

THIS ENTRY FORM MUST BE RETURNED TO THE REGISTRATION AREA BEFORE LEAVING THIS MEET.

**Proof of Age: Verification Stamp (based on Birth Certificate, Certified Baptismal Record, Passport, Driver’s License, or United States Government identification.