REGISTRATION STEP 1: ATHLETE INFOROMATION & WAIVER

Transcription

1 REGISTRATION STEP 1: ATHLETE INFOROMATION & WAIVER NAME: NSGA # Legal First Preferred Name Last (Same as fusesport Acct #) For athletes competing at more than one state s games, please use the same Legal to register with each state. DATE OF BIRTH: / / AGE: GENDER: M or F Month/Day/Year On 12/31/16 (Please Circle) ADDRESS: The FuseSPORT software requires a valid address in order to create an account & to process your registration. You will receive confirmation at the address you provide. If you do NOT have an address you can create a FREE Gmail account by visiting and clicking on the Gmail tab. ADDRESS: PO Box/Street City State Zip PRIMARY PH #: ALTERNATE PH #: EMERGENCY CONTACT: PH#: EMERGENCY CONTACT RELATIONSHIP: PERSONAL PHYSICIAN: 1. How did you learn out about the 2016 Rocky Mountain Senior Games? Past Participant Direct Mailing PSA/Press Release RMSG Website Facebook American Diabetes Expo Twitter or e-blast TV Channel 8-Greeley Department of Veteran s Affairs In Store Poster (list store): Recreation/Senior Center: Radio: Newspaper: Other: Friend/Ambassador: If you are a NEW RMSG athlete & a friend (also a 2016 RMSG participant) referred you to RMSG please list his/her name. Your friend (RMSG ambassador) will receive a $10 credit per NEW athlete who pays the base registration fee and participates in the Games! Limit $40 per ambassador. PH#: 2. Are you a Veteran? YES NO 3. If you are a SilverSneakers member please provide your membership #: 4. Are you attending the Celebration of Athletes on Friday, June 10, 6pm? No registration fee! Food & beverage purchase is optional and at your own expense. YES NO If yes, would you like to carry a sport sign during the Parade of Athletes? YES NO If yes, what RMSG sport would you like to represent? WAIVER AND RELEASE FROM LIABILITY 2016 ROCKY MOUNTAIN SENIOR GAMES I, the undersigned, understand and expressly assume the dangers of the Rocky Mountain Senior Games competition(s) which I have entered. I hereby agree to indemnify, save and hold harmless Rocky Mountain Senior Games, Colorado Senior Sports Development Council, National Senior Games Association, City of Greeley, City of Greeley Parks Department, City of Greeley Culture, Parks, and Recreation Department, Weld County Commissioners, Weld County Sheriff s Office, University of Northern Colorado, Weld County School District #6, Highland Park Lanes, Pawnee Sports Center, Work Out West, City of Lakewood, City of Westminster, Anthem Ranch Community Association/Aspen Lodge, Greeley Place, Rocky Mountain Archery, City & County of Denver, Double Diamond CrossFit and any other sponsoring agencies or their respective agents, representatives, successors or assignees for my health, safety, loss of property or injury resulting from my participation in the Rocky Mountain Senior Games and planned special events. I have prepared myself for the event(s) I have entered by practicing prior to the Rocky Mountain Senior Games. To the best of my knowledge, I have no physical restrictions which would prohibit my competing in the event(s) I have selected. I understand it would be in my best interest to consult my physician prior to my participation in regard to the Rocky Mountain Senior Games. Rocky Mountain Senior Games has my permission to have emergency medical personnel attend me during my participation in the Rocky Mountain Senior Games if it is deemed necessary. I, the undersigned, grant Rocky Mountain Senior Games and its sponsors the right to release my results and phone number to the media. I understand that I will be contacted by a Rocky Mountain Senior Games representative prior to releasing my phone number to the media. PHOTO PERMISSION: I do hereby grant permission for any still or motion pictures to be used in publicity or brochures related to the Rocky Mountain Senior Games. I have read and fully understand the refund policies as established by the Rocky Mountain Senior Games and do hereby agree to abide by those policies. I have read and understand the entry form and certify my compliance by my signature below. Signature Date 13

2 STEP 2: SINGLES & DOUBLES EVENT REGISTRATION To register, mark the box next to the event AND circle the event fee. C = Competitive (National) Events, R = Recreational (State) Events PARTNER & TEAM FINDER Are you looking for a doubles partner or do you need players for your team? Visit and hover over the Sports & Events tab to submit partner & team requests and to find other athletes looking for partners. Athletes are responsible for contacting each other and notifying RMSG when they secure a partner. You will NOT be registered for a doubles event until your partner registers and indicates you as his/her partner. ARCHERY INDOOR Sport Rocky Mountain Archery Compound Fingers (R) $2 Compound Release (R) $2 Recurve (R) $2 ARCHERY OUTDOOR Compound Fingers (C) $2 Compound Release (C) $2 Recurve (C) $2 BADMINTON CHECK HERE TO ENTER THE NON-AMBULATORY DIVISION. (C) BOWLING SINGLES (C) $9.60 Select Singles Day/Time: Wed, 6/8, 11am Thu, 6/9, 2pm DOUBLES (C) $9.60 Select Doubles Day/Time: Wed, 6/8, 11am Thu, 6/9, 2pm Fri, 6/10, 11am MIXED DOUBLES (C) $9.60 Select Mixed Doubles Day/Time Thu, 6/9, 11am Wed, 6/8, 2pm Bowling Average: Average NOT required. CHECK HERE TO ENTER THE NON-AMBULATORY DIVISION. (C) CYCLING Sport COBRAS 5K Time Trial (C) $2 10K Time Trial (C) $2 20K Road Race (C) $2 40K Road Race (C) $2 DISC GOLF 18-Hole Round (R) $2 Driving Distance Contest (R) $1 Putting Contest (R) $1 GOLF 36-Holes Scratch Play (C) $60 18-Holes Scratch Play (R) $30 List names of other RMSG athletes you would like to GOLF with: BASKETBALL Free Throw Shoot (R) $2 Hot Shot (R) $2 Three Point Shoot (R) $2 14 Golf handicap? Greeley Golf Annual Pass #: Greeley Golf Pass NOT required. Handicap NOT required.

3 PICKLEBALL SINGLES (C) $5 DOUBLES (C) $5 MIXED DOUBLES (C) $5 USAPA Rating: Rating NOT required. PICKLEBALL VOLUNTEER REFEREES NEEDED Singles Referee-Wed, 6/10 Afternoon (1-6pm) Mixed Doubles Referee-Thu, 6/11 Morning (8am-1pm) Afternoon (1pm-6pm) Doubles Referee-Fri, 6/12 Morning (8am-1pm) Afternoon (1pm-6pm) POWER LIFTING Sport Double Diamond CrossFit Bench Press (R) $2 Deadlift (R) $2 Squat (R) $2 POWER WALKING 400 Meter Power Walk (R) $ Meter Power Walk (R) $2 RACE WALK 1500 Meter Racewalk (C) $ Meter Racewalk (C) $2 RACQUETBALL USRA Member #: USRA membership IS required and can be purchased for $20 from the tournament director. ROAD RACE 5K Foot Race (C) $2 10K Foot Race (C) $2 ROWING 2000 Meter Timed Event (R) $2 SHOOTING Skeet Shoot - 50 Rounds (R) $14 Trap Shoot - 50 Rounds (R) $14 SHUFFLEBOARD CHECK HERE TO ENTER THE NON-AMBULATORY DIVISION. (C) SWIMMING Entry Time USMS Recognition #326-R003 Not Required 50Y Backstroke (C) $2 50Y Breaststroke (C) $2 50Y Butterfly (C) $2 50Y Freestyle (C) $2 100Y Backstroke (C) $2 100Y Breaststroke (C) $2 100Y Butterfly (C) $2 100Y Freestyle (C) $2 100Y Ind. Medley (C) $2 200Y Backstroke (C) $2 200Y Breaststroke (C) $2 200Y Butterfly (C) $2 200Y Freestyle (C) $2 200Y Ind. Medley (C) $2 400Y Ind. Medley (C) $2 500Y Freestyle (C) $2 25Y Backstroke (R) $2 25Y Breaststroke (R) $2 25Y Elem. Backstroke (R) $2 25Y Front Crawl (R) $2 25Y Sidestroke (R) $2 25Y Butterfly (R) $2 50Y Sidestroke (R) $2 USMS Membership #: USMS membership is NOT required. TABLE TENNIS 15

4 TENNIS USTA Rating: USTA rating not required. If you play in a USTA league that conflicts with RMSG Tennis, what day & time is the conflict? TRACK & FIELD/THROWING Discus (C) $2 High Jump (C) $2 Javelin (C) $2 Long Jump (C) $2 Shot Put (C) $2 Triple Jump (C) $2 Pole Vault (C) $2 Frisbee Toss (R) $2 Football Throw(R) $2 Softball Throw (R) $2 Hammer Throw (C) $2 Weight Throw (R) $2 50 Meter Dash (C) $2 100 Meter Dash (C) $2 200 Meter Run (C) $2 400 Meter Run (C) $2 800 Meter Run (C) $ Meter Run (C) $2 STEP 3: TEAM EVENT REGISTRATION DIRECTIONS: ONLY team captains/mangers/reps for Bocce & Bowling need to complete this step and can register teams online or by mailing a complete roster & payment to: RMSG, 1010 Sixth Street, Greeley, CO Athletes competing in singles and/or doubles events in addition to a team event need to complete a separate registration for those events. Athletes competing in ONLY Bocce or Team Bowling are NOT required to pay the Base Registration fee. Bocce and Bowling team fees do NOT include free t-shirts for team members. T-shirts can be purchased by completing the t-shirt order form. BOCCE Team Open (R) $80/team (4 members, any combo of men and/or women age 50+) BOWLING Team Mixed Gender (R) $65/team (4 members, 2 men & 2 women) Select Team Bowling day & time: Wed, 6/8 11am Wed, 6/8 2pm Fri, 6/10 11am Team Name: Captain Address: Captain Phone: Captain Name: PO Box/Street City State Zip Captain Team Member Name address required Address City, State, Zip Phone # Gender Date of Birth SINGLES, DOUBLES & TEAM EVENT FEES SUBTOTAL...$ Add up Event s from p and transfer this subtotal to p.17, PAYMENT CALCULATION. 16

5 STEP 4: T-SHIRTS, SOCIAL EVENTS, MEALS & PAYMENT SOCIAL EVENTS Total Celebration of Athletes June 10, 6pm FREE $0 10K Fun Run/Walk June 9, 7:30am $5 Must be under age 50 to enter Fun Run/Walk. 8-ball Tournament June 11, 9am $5 5K Fun Run/Walk June 12, 7:30am $5 Must be under age 50 to enter Fun Run/Walk. 9-ball Tournament June 12, 9am $5 Curling June 8, 2:30pm Reservation required. T-SHIRT ORDER Design by Nanci Avery FREE Athletes who pay the RMSG Base Registration receive ONE FREE T-shirt (unisex sizes). Please circle ONE choice: Small Medium Large XL 2XL Donate my t-shirt Purchase T-shirts: Size Qty Total Small $6 Medium $6 Large $6 XL $6 2XL $7 17 MEALS Qty Total Lunch Thu, June 9 $5 Taco Salad, Corn Bread, Cookie Lunch Fri, June 10 $5 Egg Salad Sandwich, Chips, Pickle, Cake Lunch Sat, June 11 $5 BBQ Pork Sandwich, Potato Salad, Cottage Cheese, Cookie Lunch Sun, June 12 $5 Lasagna, Salad, Garlic Bread, Brownie PAYMENT CALCULATION Total Include payment for appropriate Base Registration fee (see dates below). If you are participating in ONLY Team Events OR ONLY purchasing t-shirts, social events & meals, you DO NOT have to pay the Base Registration fee. Early Bird Base Registration $40 POSTMARKED ON OR BEFORE MAY 6, 2016 Late Base Registration $50 POSTMARKED MAY 7-18, 2016 Social Events, Meals & T-shirt s (from this page) Singles, Doubles & Team Event s (Subtotal from page 16) Donate to CSSDC (optional) CSSDC is a 501(c)3 non-profit organization and governs Rocky Mountain Senior Games Processing $ 7 (required for singles & doubles event registration) GRAND TOTAL $ PAYMENT METHOD Credit Card Cash Check # CREDIT CARD AUTHORIZATION (Check Credit Card Type) MasterCard Visa AMEX Discover Card Number Expiration Date / Month Year Name on Credit Card: Signature: Date: 3-digit Security # (on back of card)

6 Volunteer Form Please circle your choices. You may circle more than one day and shift, if you are available! The times listed are the maximum hours. Hours may vary slightly after participant registrations are received in June. Mail, or fax this schedule page to RMSG. Visit our website for more informationn Please contact Sheri or Confirmation of your volunteer assignments by June 1, 2016 RC Recreation Center / SC Senior Center / FFP - Family FunPlex Wednesday June 8 10am -noon Noon-6pm (must know rules) Thursday June 9 Registration@ SC 6am 6pm (2 hour shifts) Kitchen 6am 6pm (1-3 hour shifts) 10K Foot Park 7am -9am Park Lanes 11am -4pm FFP 9am noon / noon 4pm 7am 1pm 9am noon / 1-3pm 8-4pm (must know rules) Friday June 10 SC 6am 6pm (2 hour shifts) Kitchen 6am 6pm (1-3 hour shifts) RC 8am -6pm (2 hour shifts) Park Lanes 11am-2pm 8-4pm (must know rules) Field Events@ Heath Middle School 8:30am-12:30pm Ie: Discus, Javelin, High/Long /Triple Jump, Shot Put, Pole Vault Frisbee, Football, /Softball Middle School, 1pm Track@ Heath Middle School 11-2pm / 2 4pm Indoor 1-4pm Saturday, June 11 6am-6pmm (2 hour shifts) Kitchen 6am-6pmm (1-3 hour shifts) Outdoor 8am- noon RC 8am-6pmm (2 hour shifts) (van leaves from SC 6:30 to Take Volunteers to site) 7am 12:30pm Table RC 8:45 noon/ noon -4pm 8-ball@SC 9- noon / 1-3pm Hammer/Weight 1-3pm / 3-5pm 1:15pm 4pm Sunday June 12 6am 2pm (2 hour shifts) Kitchen 6am 2pm (1-3 hour shifts) 5k foot 7am 10am 5K race 7am 9am (van leaves from SC 6:30 to Take volunteers to site) 7am 12:30pm 9-ball@SC 9am noon Table Tennis@ RC 9am-12: :30pm Swimming@ RC 1:15-4pm Personal Information one name per form. Note: volunteers must be 16 + years to receive t-shirt Name Agency/Group/Club (ie. Statefarm) Address Birth Month & Day Street City State Zip By providing us your we will correspond wit you via for faster and more efficient communication. Watch for confirmation and other news via . Please print clearly. Thank you Phone number WAIVER AND RELEASE FROM LIABILITY I, the undersigned, understand and expressly assume the dangers of the Rocky Mountain Senior Games competition(s) which I have volunteered. I hereby agree to indemnify, save and hold harmless Rocky Mountain Senior Games, Colorado Senior Sports Development Council, National Senior Games Association, City of Greeley, City of Greeley Culture, Parks, and Recreations Department, Weld County Commissioners, Weld County Sheriffs Office, University of Northern Colorado, Weld County School District #6, Highland Park Lanes, Pawnee Sports Center, Work Out West, City of Lakewood, City of Westminster, Anthem Ranch Community Association/Aspen Lodge, Greeley Place, Rocky Mountain Archery, City & County of Denver Double Diamond CrossFit and any other sponsoring agencies or their respective agents, representatives, successors or assignees for my health, safety, loss of property or injury resulting from my participation in the Rocky Mountain Senior Games events. I have prepared myself for the event(s) I have entered by practicing prior to the Rocky Mountain Senior Games. To the best of my knowledge, I have no physical restrictions which would prohibit my competing in the event(s) I have selected. I understand it would be in my best interest to consult my physician prior to my participation in regard to the Rocky Mountain Senior Games. Rocky Mountain Senior Games has my permission to have emergency medical personnel attend me during my participation in the Rocky Mountain Senior Games if it is deemed necessary. I, the undersigned, grant Rocky Mountain Senior Games and its sponsors the right to release my results and phone number to the media. I understand that I will be contacted by a Rocky Mountain Senior Games representative prior to releasing my phone number to the media. PHOTO PERMISSION: I do hereby grant permission for any still or motion pictures to be used in publicity or brochures related to the Rocky Mountain Senior Games. I have read and fully understand the refund policies as established by the Rocky Mountain Senior Games and do hereby agree to t abide by those policies. I have read and understand the entry form and certify my compliance by my signature below. Signature Date Mail: RMSG Volunteer th Street Greeley CO Fax: Sheri.Lobmeyer@greeleygov.com 18