Location:

102-171 Samborski Drive

Oak Bluff, Manitoba

R4G 0B3

Entry Fee: $80 Junior Olympic Levels 5-10

$60 Regional Stream

Entry Deadline: November 21st, 2016

Cheques made payable to Winnipeg Gymnastics Centre.

Registrations must include payment & waiver forms.

Any registrations received after November 21st, 2016 will be charged a $20 late fee per athlete.

No registrations accepted after December 2nd, 2016. Space is limited. Registrations will be taken on a first come first serve basis.

Refunds:

Refund requests will only be accepted if accompanied by a medical certificate indicating reason for withdrawing from the competition. A $40 administration fee will be charged as per the technical regulations.

Refunds will not be accepted past December 2nd, 2016.

Awards and Equipment:

As Per Technical Regulations

Only Registered Coaches will be allowed on the gym floor.

Once all registrations are received the final schedule will be emailed and posted on the WGC website:

Any questions can be directed to Celia Champion or WGC office staff @ 204-475-9872 or by email at

Women’s Junior Olympic Levels 5-10 and Regional Intermediate, Advanced and Pre-Provincial Invitational December 17th & 18th, 2016

Entry Form

Club: ______Contact Person: ______

Email: ______Phone Number: ______

Coaches:

1)______GCG# ______

2)______GCG# ______

3)______GCG# ______

4)______GCG# ______

5)______GCG# ______

6)______GCG# ______

Name / Birthdate
MM/DD/YY / GCG# / Level / Age Group / Fee

Please list your athletes in order of level and age.

Please list your athletes in order of level and age.

Name / Birthdate
MM/DD/YY / GCG# / Level / Age Group / Fee

All Athletes must complete this form

This personal information is being collected for use in the case of a medical emergency, and to determine eligibility, age group and appropriate level of competition. This information will be destroyed immediately following the competition.

PART I – PERSONAL INFORMATION

Name: ______Birthdate (MM/DD/YYYY) ______

Address: ______City/town: ______

Postal code: ______Phone number: ______Email: ______

PART II – MEDICAL INFORMATION

Family physician: ______Address: ______

Phone number: ______

Name of Parents and/or Guardian (if under 18): ______

Phone Number: (home) ______(Work) ______(Mobile) ______

Emergency Contact Name and Phone Number: ______

List any medical conditions that competition personnel should be aware of: ______

List any medications currently taking: ______

List any allergies: ______

PART III – WAIVER & PERMISSIONS

In consideration of your acceptance of my participation I, intending to be legally bound, do hereby, for myself, my heirs, executors and administrators waive and release and forever discharge any and all rights and claims for losses, damages and/or injuries which I may have or may hereafter accrue to me against the Winnipeg Gymnastics Centre, the Organizers or their respective officers, agents, representatives, and/or assigns for any and all losses, damages and injuries which may be sustained and suffered by me in connection with my association with or entry in this competition, any activities associated with, or which may arise out of my traveling to, participating in and returning from, said event.

I give permission for emergency medical/surgical care to be given by local practitioners in Manitoba. It is understood that wherever possible the above designated emergency contact person shall be contacted, informed of the problem, diagnosis, treatment required and hoped for result.

As per the Canadian Privacy Act, consent is required to publish a participant’s name and competition results in the media. Unless otherwise indicated in writing, I give permission to publish my/the participant’s name, club and results achieved at this competition.

______

Participant SignatureDate

______

Parent/Guardian Signature (if under 18)Date

Relationship to Participant: ______