2015 USATF NATIONAL JUNIOR OLYMPICS
WAIVER & ENTRY FORM
PER 2015 USATF COMPETITION RULE BOOK, USATF RULE 305.2(B):
Athletes who compete in the Junior National Championships, World Youth Track Trials, or United States Olympic Selection Competition may be entered in the National Junior Olympic meet without having to compete in the Association or Regional meet provided that they meet the Youth Athletics age limits. Acquisition of the waiver and completion of the entry to the National meet must be made prior to the Regional meet via the Regional Coordinator.
(Please print)
First Name______Last Name______
2015 USATF Membership # _ / _/_/_/_/_/_/_/_/_
USATF Association______Region______
USATF Club Name ______
Age Division______Date of Birth __/__/____ Male____ Female______
Please list event(s) in which you competed in at Junior Nationals, Youth Olympic Game Trials, and/or the World Youth Trials
EVENT TIME/MARK EVENT TIME/MARK
1. 3.
2. 4.
Please list event(s) in which you are going to compete: list place and time/mark achieved at the event checked above.
EVENT TIME/MARK PLACE EVENT TIME/MARK PLACE
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2015 USATF NATIONAL JUNIOR OLYMPICS
WAIVER & ENTRY FORM
1.______
2. ______
3.______
4.______
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2015 USATF NATIONAL JUNIOR OLYMPICS
WAIVER & ENTRY FORM
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2015 USATF NATIONAL JUNIOR OLYMPICS
WAIVER & ENTRY FORM
COMBINED EVENT ______TOTAL PTS______PLACE______
Entry Fees: $8.00 per individual event - $24.00 for Heptathlon or Decathlon
· Athlete’s Release: I voluntarily agree to participate in the 2015 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 2015 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 "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 2015 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.
· Athletes who participate in this competition may be subject to drug testing.
Visit the competition's Athlete Information page (http://www.usatf.org/Events---Calendar/2014/USATF-National-Junior-Olympic-Outdoor-Track---Fiel.aspx) 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: ______
Please note: All requests for accommodations must be received six weeks prior to the date of competition. Visit www.usatf.org/about/legal/policies/ADA.asp for forms and procedures)
List allergies and current medications: ___none______
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2015 USATF NATIONAL JUNIOR OLYMPICS
WAIVER & ENTRY FORM
Submission Instructions: Mail waiver form & entry fees to your Regional Coordinator listed on Page 2. Forms MUST be received before your Regional Championship Meet. Contact your regional coordinator or check the USATF website for Region dates.
Mail Form & Fees to your Youth Regional Coordinator Listed Below
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2015 USATF NATIONAL JUNIOR OLYMPICS
WAIVER & ENTRY FORM
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2015 USATF NATIONAL JUNIOR OLYMPICS
WAIVER & ENTRY FORM
Region 1 Coordinator
Bill Mongovan
Address: 1169 Hope St. B-4
Stamford, CT 06907
Phone: (203) 722-1276
E-mail:
Region 2 Coordinator
Cindy Long
Address: 109 Evans Drive
McMurray, PA 15317
Phone: (724) 941-5639
E-mail:
Region 3 Coordinator
Henry McCallum
Address: 7949 Dellwood Ave.
Glenarden, MD 20706
Phone: (301) 322-7356
E-mail:
Region 4 Coordinator
Thaddeus Sligh
Address: 14 Peach Grove Place
Mauldin, SC 29662
Phone: (864) 230- 3995
E-mail:
Region 5 Coordinator
James Engel
Address: 6565 Stewart Road
Cincinnati, OH 45236
Phone: (513) 608-8766
E-mail:
Region 6 Coordinator
Mary Birdwell
Address: 2430 Rockcreek Road
Hoover, AL 35226
Phone: (205) 862-2477
E-mail:
Region 7 Coordinator
Brenda Kimbrough
Address: 10735 W Beach Rd
Beach Park, IL 60087
Phone: (847) 782-9716
E-mail:
Region 8 Coordinator
Rubin Carter
Address: 6915 N. 118th Circle
Omaha, NE 68142
Phone: (402) 203-9190
E-mail:
Region 9 Coordinator
Forika McDougald
Address: 812 South Clay
Junction City, KS 66441
Phone: (785) 375-6754
E-mail:
Region 10 Coordinator
Liza Mascareñas
Address: PO Box 231
Vandito, NM 87579
Phone: (505) 550-9887
E-mail:
Region 11 Coordinator
Florence Erickson
Address: 523 E Spruce
Caldwell, ID 83605
Phone: (208) 454-1179
E-mail:
Region 12 Coordinator
Felicia Love
Address: 14127 Willow Mtn.
Houston, TX 77047
Phone: (832) 433-6094
E-mail:
Region 13 Coordinator
Char Engelhardt
Address: 22321 3rd Ave SE
Bothell, WA 98021
Phone: (425) 489-9433
E-mail:
Region 14 Coordinator
David Lawrence
Address: 7887 Grandstaff Drive
Sacramento, CA 95823
Phone: (916) 207-8842
Region 15 Coordinator
Lance Miller
Address: 1162 Dana Maple Court
Las Vegas, Nevada 89123
Phone: (702) 561-7370
E-mail: track2471@yahoo .com
Region 16 Coordinator
See Region 12
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2015 USATF NATIONAL JUNIOR OLYMPICS
WAIVER & ENTRY FORM
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2015 USATF NATIONAL JUNIOR OLYMPICS
WAIVER & ENTRY FORM
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