LOUDOUNCOUNTY

LOCAL HERSHEY TRACK AND FIELD MEET

Sunday, May 7, 2006

2:00 p.m.

HeritageHigh School

Rain Date: Wednesday, May 10, 2006 at 6:00 p.m.

Registration Deadline May 1, 2006

Name: / Sex: (Circle One)
M / F
Address:
City: / State: / Zip:
Phone:
(___) ______ / Date of Birth:
___/___/___ / Competing Age: (Age as of Dec. 31, 2006)
______
Shirt Adult Size: All Participants must complete. (For children who advance to the district meet)

Participants can enter either two track and one field or two field and one track event up to and including the State Meet. Please circle the events you wish to participate in at this meet.

Boys Born in 1996-97Girls Born in 1996-97

1. 50 Meter Dash1. 50 Meter Dash

2. 100 Meter Dash2. 100 Meter Dash

3. 200 Meter Dash3. 200 Meter Dash

4. 400 Meter Dash4. 400 Meter Dash

5. 4 X 100 Meter Relay5. 4 X 100 Meter Relay

6. Standing Long Jump6. Standing Long Jump

7. Softball Throw7. Softball Throw

Boys Born in 1994-95Girls Born in 1994-95

1. 100 Meter Dash1. 100 Meter Dash

2. 200 Meter Dash2. 200 Meter Dash

3. 400 Meter Dash3. 400 Meter Dash

4. 800 Meter Dash4. 800 Meter Dash

5. 4 X 100 Meter Relay4. 4 X 100 Meter Relay

6. Standing Long Jump6. Standing Long Jump

7. Softball Throw7. Softball Throw

Boys Born in 1992-93Girls Born in 1992-93

1. 100 Meter Dash1. 100 Meter Dash

2. 200 Meter Dash2. 200 Meter Dash

3. 800 Meter Dash3. 800 Meter Dash

4. 1600 Meter Dash4. 1600 Meter Dash

5. 4 X 100 Meter Relay5. 4 X 100 Meter Relay

6. Standing Long Jump6. Standing Long Jump

7. Softball Throw7. Softball Throw

Relay Teams Must Be Formed by May 1st

(All four team members must be entered below with full names to be eligible)
(Teams must turn in all four individual registration forms together to be eligible)

Relay team (circle Year Born) BoysBorn In: 1996-971994-951992-93

1. ______2. ______

3. ______4. ______

Relay team (circle Year Born) GirlsBorn In: 1996-971994-951992-93

1. ____________2. ______

3. ______4. ______

Registration can either be Mailed, Faxed or Delivered, by May 1, 2006:
Hershey Track & Field Meet
60 Ida Lee Drive, NW

Leesburg, VA20176

ATTN: Jeremy Payne
Fax: 703-737-7165

ELIGIBILTY REGULATIONS

REQUIREMENTS

  • All participants must compete in their age group and sex division.
  • A birth certificate or a notarized statement must be presented to the sponsoring recreation department before the district meet.

School attending: ______

EMERGENCY INFORMATION

Parents or Guardian Name: ______

Emergency Phone Number: ______

Emergency number other than that listed: A close relative to be notified.

WAIVER

The above named participant and the participant’s parent/guardian have requested registration of the participant in the Hershey Youth Program. In consideration of such registration, the right of the participant to compete in the Hershey Youth Program and the use by the participant of the sponsoring agency’s facilities and equipment, both the participant and the parent/guardian each acknowledge that the participant will be competing in the Hershey Youth Program and sponsoring agency’s facilities at the participants sole risk and the participant on his or her own behalf and on behalf of his or her heirs, executors, administrators and assigns hereby releases, discharge and agree to hold harmless Hershey Foods Corporation and its franchises and the National Recreation and Park Association, the National Association for Sport and Physical Education, the President’s Council on the Physical Fitness and Sports, the Town of Leesburg Parks and Recreation Department, and the Department of Loudoun County Parks, Recreation and Community Services. We also agree to allow the Hershey Youth Program to use and reproduce the participant’s name and/or likeness and/or information concerning the participant and to circulate the same for any and all purposes in any manner. We certify that the information on the participation form is correct.

(Signature of Parent/Guardian) ______