Individual
Event Entry Form
West Virginia Amateur
2003
CROSS COUNTRY CHAMPIONSHIPS
November 15, 2003 10:00
am Coonskin Park/Charleston,
West Virginia
Complete this form and submit
with entry fee $5.00 per athlete (non-refundable). Payment must be made payable to: Capital City
Striders, Inc./Post Office Box 1243/Charleston, West Virginia 25325
All runners must have current AAU Card and/or USATF
Card. Year 2004 cards can be purchased
with the entry for $12.00 for youth
runners and $15.00 for those over 18.
Note: Except for signature,
please PRINT or TYPE all information.
NAME:
Last
_____________________________________ First
__________________________
Middle Initial __________
ADDRESS: ________________________________ CITY:
_____________________
STATE: _______ ZIP CODE: ________
Club Name (if none, leave
blank) _______________________________
Association: West Virginia Region Number: V or VI
Card Type (USATF or AAU
or Both)
Card Number
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Athlete’s
Release: In consideration of this entry being accepted, I/we shall be legally
bound and do release for myself, heirs, executors, and administrators any claim
for loss, injury or damage which may
occur during participation in or traveling to and from this event and do hereby
release Capital City Striders, Inc., WV AAU, Kanawha County, Coonskin Park,
meet officials and others assigned from any claim.
I/we
grant permission to the Meet Directors, Coaches, and Chaperones to act upon
this athlete as a guardian/spokesperson in granting permission for the use of
emergency medical treatment, including anesthesia, if necessary. I understand that should a medical emergency
arise, an attempt will be made to notify, but that authorization is hereby
granted.
A
copy of the proof of age and an AAU membership number must be provided with the
official entry.
__________________________________________________________________________________________________________________
Signature - ATHLETE Must
be signed if athlete is under 18 years of age
__________________________________________________________________________________________________________________
Signature - PARENT,
GUARDIAN
Telephone:
Home ( )
________________ Work
( ) ____________________
List allergies and current medication(s):
______________________________________________________________________________
______________________________________________________________________________
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. Information regarding drugs and drug testing
may be obtained by calling the USOC hot line at 800-233-0393.
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Age Divisions (circle
appropriate group) Bantam
Boys (born 1993 & later) Bantam Girls (born 1993 & later) Midget
Boys (born 1991 - 1992) Midget Girls
(born 1991 - 1992) Youth
Boys (born 1989 - 1990) Youth Girls
(born 1989 - 1990)
Intermediate Boys (born 1987 - 1988) Intermediate Girls (
1987 - 1988) Young Men (born 1985 - 1986) Young Women
(born 1985 - 1986)
Birth Date: |__________|_________|__________|
Month Day Year |
Top twelve AAU
individuals quality for Nationals held
December 6, 2003 in Dayton, OH.
Top twenty-five USATF
individuals quality for Regional held November 22, 2003 in Cleveland, Ohio.
NOTE: Please be sure you have completed ALL
information.
Proof of Age: Birth certificate, certified Baptismal
Record, Passport, Driver’s License, or U.S. Military Identification must be
attached.