2016 Para-Athletic Program Mid-Atlantic Games REGISTRATION

Transcription

1 2016 Para-Athletic Program Mid-Atlantic Games REGISTRATION Athlete Last Name: First Name: Birth Date: Classification: Track Field Swimming Athletes must be classified before events. CAMC Para-Athletics will host a free classification and sports clinic in Charleston, WV, at the YMCA on April 9, Contact Zachary Szasz for more information at (304) or zachary.szasz@camc.org. Gender Male Female Address Street Address: Address Line 2: City: State: Zip Code: Phone Number: Address: IPC Membership Number: Emergency Contact Last Name: First Name: Phone Number: Relation to Athlete: Shirt Size Youth Small Youth Medium Youth Large Adult Small Adult Medium Adult Large Adult X-Large Adult 2XL Adult 3XL Other (please specify):

2 Team (if applicable) Coach s Last Name: Coach s First Name: Team Name / Organization (if applicable): Coach s Address: Coach s Phone Number: Event Registration Competing as: Division Future (U7) (5,6) U11 (7,8,9,10) U14 (11,12,13) U17 (14,15,16) U23 (20,21,22) Adult (23-24) Masters (35 or older) AIR RIFLE / PISTOL (add $10 per event if participating in either or both of these) Events: SH1 SH2 SH3 Must have own equipment or sighter Select: May 7, :00 a.m. ARCHERY Classification: AR1 (Bowstand) AR2 (Wheelchair) AR3 (Ambulatory) Bow Type: Recurve Compound Crossbow Exhibition Events

3 TRACK Classification: Please include classification with the events in which you wish to compete. If you don t know your classification, please be sure to fill in this field as unclassified. Track Events: 60m 100m 100m Powerchair 200m 400m 800m 1,500m 5,000m 10,000m Handcycle (5,000m and 10,000m only) FIELD Classification: Please include classification with the events in which you wish to compete. If you don t know your classification, please be sure to fill in this field as unclassified. Field Events: Discus Shotput Club Javelin Turbo Javelin Long Jump SWIMMING Classification: Please include classification with the events in which you wish to compete. If you don t know your classification, please be sure to fill in this field as unclassified. Swimming Events: 25 Free 50 Free 100 Free

4 200 Free 500 Free 25 Back 50 Back 100 Back 25 Fly 50 Fly 100 Fly 25 Breast 50 Breast 100 Breast WEIGHTLIFTING Weight Classification: Please include your body weight in kilograms, and please make note of male or female weights when identifying your competitions weight. Weightlifting Events: Bench Press Powerlift Weight Classes: Male Division Female Division A) Up to 48kg. A) Up to 40kg. B) to 52kg. B) to 44kg. C) to 56kg. C) to 48kg. D) to 60kg. D) to 52kg. E) to 67.50kg. E) to 56kg. F) to 75kg. F) to 60kg. G) to 82.50kg. G) to 67.50kg. H) to 90kg. H) to 75kg. I) to 100kg. I) to 82.50kg. J) Over 100kg. J) Over 82.50kg.

5 *IMPORTANT* All athletes are strongly recommended to become members of Adaptive Sports, USA (formerly Wheelchair and Ambulatory Sports USA) before registration at the Games. If you are not an Adaptive Sports, USA member, your results from this competition will not be placed in the database and you will not be eligible for a national record for an eligible event. You can apply online by visiting WAIVER AND RELEASE OF PARTICIPATION: I warrant that I am physically able to engage in the Para- Athletic Program s Mid-Atlantic Games and I have no medical condition which would prevent my full participation in this event. I knowingly, voluntarily and expressly waive, on behalf of me, my heirs and personal representatives, any claim that I or they may have against the Mid-Atlantic Wheelchair Athletic Association or Charleston Area Medical Center (CAMC) for injury or damages, including death, which I may sustain as a direct or indirect result of participating in this event. I forever release, waive, discharge and covenant not to sue the Mid-Atlantic Wheelchair Athletic Association or CAMC, its trustees, officers, employees, agents and volunteers, for any injury or damages, including death, directly or indirectly resulting from my participation in this event. I have read the foregoing waiver and release of liability and fully understand its contents. Signature (guardian if under 18): Date: PHOTO RELEASE I hereby authorize the Mid-Atlantic Wheelchair Athletic Association and Charleston Area Medical Center (CAMC) to copyright and/or publish any and all photographs, videotapes and/or film in which I and/or the minor participants appear while attending these events. I further agree that the Mid-Atlantic Wheelchair Athletic Association and CAMC may transfer or use these photographs, videotapes or film for any exhibitions, public displays, promotions, publications or advertising purposes without limitations or reservations. Signature (guardian if under 18): Date:

6 FEES Check all that apply: $45 Entry Fee $5 Participant Fee (for all non-athletes, including family members and/or coaches) Additional: $75 Late Fee (if received after April 24, 2016 no exceptions) $10 for Marksman Air Rifle event $10 for Marksman Pistol event $10 if you are NOT an Adaptive Sports, USA member (valid for this meet only) $10 for any *extra* shirts (more than the one included in registration for family members/coaches) -Size(s): TOTAL: $ I AM PAYING: WITH A CREDIT CARD Name on credit card: Address: Phone Number: Address: Total amount to be charged on card: $ Credit Card (please select): Visa MasterCard American Express Credit Card Number: Expiration Date: CID Number: WITH A CHECK (I will mail this registration form and check via the postal service.) I understand if my registration form and check are not postmarked by April 22, 2016, I will need to pay the additional $75 late fee. Make check payable to CAMC Foundation. Mail to: CAMC Foundation Para-Athletic Program 3412 Staunton Avenue Charleston, WV Thank you! We look forward to seeing you at the Mid-Atlantic Games!