Individual
Event Entry Form
West Virginia Amateur
2004
CROSS COUNTRY CHAMPIONSHIPS
November 6, 2004 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, WV 25325
All runners must have current AAU Card and/or USATF
Card. Year 2005 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 1994 & later) Bantam
Girls(born 1994 & later) Midget
Boys (born 1992 - 1993) Midget
Girls(born 1992 - 1993) Youth
Boys (born 1990 - 1991)
Youth Girls (born 1990 - 1991) Inter.Boys (born 1988 - 1989) Inter.Girls (born 1988 - 1989) Young
Men (born 1986 - 1987)
Young Women (born 1986 - 1987)
Birth Date:
|__________|_________|__________| Month Day Year |
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Top twelve AAU
individuals quality for Nationals held December 4, 2004 in Kingsport, TN.
Top twenty-five
USATF individuals quality for Regional held November 20, 2004 in Louisville KY.
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.