ROSELAND RECREATION DEPARTMENT

973/403-6822

Mayor John Duthie

2014JR. OLYMPICS

The JUNIOR OLYMPICS is a track and field competition for Roseland resident children ages 5through 12 (as of June 20th). Each participant may enter up to 4 events. Awards will be presented to all 1st, 2nd, and 3rdplace winners in each event and overall in each age category. NO CLEATS - SNEAKERS ONLY!

Age Groups: 5-6, 7-8, 9-10 and 11-12 (Boys and Girls are separated for events)

Date:Friday, June 20, 2014

Where:O’Beirne and Harrison Fieldsfrom 6:00p.m. – 9:00 p.m. (Includes Awards)

Check in:5:30p.m. – 6:00p.m. (Numbers will be distributed at that time)

*Important:Please note the events you have selected (below) for your records:

Field Events: Shot Put __, Running LongJump __, and Softball Throw__

Track Events: 50 yd. dash __, 110 yd. dash __, 220 yd. dash __, 440 yd. dash __ and Steeple Chase__

In case of inclement weather call 973/226-6552 opt. #3 - no earlier than two hours before the event.

Please return complete form no later than Thursday, June 19, 2014.(NO SAME DAY SIGNUPS)

Mail to or drop off to: Roseland Recreation140 Eagle Rock AvenueRoseland, NJ 07068

(Detach Here)

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One form per participant 2014 Junior OlympicsParticipant Number ______

(Office use only)

NAME ______E-MAIL ADDRESS ______

ADDRESS ______TOWN/CITY ______STATE___ ZIP______

HOME PHONE ______EMERGENCY PHONE ______

EMAIL______AGE _____ BIRTH DATE ______SEX: M____ F ____

AChild May Only EnterUp To 4 Events

Field Events (6:00 p.m.-7:30 p.m.) Track Events (7:30 p.m. - 9:00 p.m.)

Running Long Jump (all ages) ______50 Yard Dash (all ages) ______

Shot Putt (all ages) ______

Softball Throw (all ages)

110 Yard Dash (ages 5-6)______

220 Yard Dash (ages 7-8) ______

220 Yard Dash (ages 9-10) ______

440 Yard Dash (ages 11-12) ______

Steeple Chase (ages 7-8)

Steeple Chase (ages 9-10)

Steeple Chase (ages 11-12) ______

In consideration of this entry being accepted, I hereby for myself, heirs, executors and administrators, waive and release any and all claims that I may have against The Roseland Recreation Department, The Roseland Board of Education, The Roseland Police and First Aid Squads, or those representatives, successors, assignees and any other sponsors of this event (hereafter to be known as the Group), for any injuries that may be suffered by me in this event. It is also understood by me that the Group provides no insurance coverage for this event and I attest that I am in physical condition for this event. I also understand that I will not hold the group responsible for any publicity used concerning this event and that entry fees are non-refundable.

NOTICE- Any written statement made on this from, which the writer knows to be false or one which the writer does not believe to be true, is punishable under New Jersey law as a crime of the fourth degree (2C-28-3).

Child Photo / Video / Release Form

I grant permission for the Borough of Roseland, Roseland, New Jersey to use photograph(s)/moving image(s) of my child participating in Borough programs and/or activities for promotional purposes. I understand that photographs or recordings may be utilized by the Borough at its discretion

for materials including, but not limited to: newsletters, brochures, television, video tape and flyers. Photographs sent to the local

newspaper may have names noted. There will be no valuable consideration paid as a result of this activity. Yes ___No ___

Parent’s/Guardian’s Signature ______Date ______

(I have read and understood all event information)

For information on all Recreation Programs use Channel 35 or Verizon 46, or look in “The Progress” newspaper.