Unit 5, Heathcoat Building, Nottingham Science & Technology Park, University Boulevard, Nottingham, NG7 2QJ.

Telephone: 0115 925 7027. Email:

Find out more about the work of CP Sport at

A Limited Company registered in England and Wales, no 04181593. Registered office as shown. Registered Charity No: 1088600

CP Sport Registration Form

Unit 5, Heathcoat Building, Nottingham Science & Technology Park, University Boulevard, Nottingham, NG7 2QJ.

Telephone: 0115 925 7027. Email:

Find out more about the work of CP Sport at

A Limited Company registered in England and Wales, no 04181593. Registered office as shown. Registered Charity No: 1088600

Event: Athletics Series 2016

Participant Details:

Mr Mrs Ms Miss Other

Full Name:

Address:

Post Code:

Tel No.:

Date of Birth:

Age:

Email:

CP Sport Membership No.:

Athletics Club: ______

Classification (if known):______

IPC SDMS Number (if known):______

URN Number (England Athletics No):______
Parent / Guardian / Emergency Contact:

Mr Mrs Ms Miss Other

First Name:

Surname:

Emergency phone no:

Email:

How did you find out about this event?_____

Medical Details:

Please indicate if you have any medical conditions or any other special requirements we should be aware of e.g. asthma, allergies.

Impairment:

Cerebral Palsy Visual impairment Dwarf

Wheelchair Learning Disability Amputee

Other ______

Compete from:

Wheelchair RaceRunner Throwing Frame

Compete standing: Yes No

Igive permission for the named participant to take part in this CP Sport event. In the event of an accident or emergency, I give permission for any immediate treatment deemed necessary by a qualified first aider/medical practitioner.

Would you like to receive regular e-mail updates through our CP Sport newsletter?

Yes No

Participant signature (parent/guardian if under 18 years)

Date:

Unit 5, Heathcoat Building, Nottingham Science & Technology Park, University Boulevard, Nottingham, NG7 2QJ.

Telephone: 0115 925 7027. Email:

Find out more about the work of CP Sport at

A Limited Company registered in England and Wales, no 04181593. Registered office as shown. Registered Charity No: 1088600

Maximum
3 events per competition / Athletics Series 2016 / National Athletics Championships
Event
(please tick) / Stoke Mandeville 4th & 5th June 2016 / Doncaster
25th June 2016 / Stoke Mandeville 13th & 14th August 2016 / Gateshead
28th August 2016 / Nottingham 24th September 2016 * Separate payment required
60m (under 11’s only)
100m
200m
400m
800m
1500m
3000m
Discus
Shot
Javelin
Club
Long Jump
Howler (under 11’s only)
Spungdis (Class 31 only)
Javball (Class 31 only)

Entry Forms along with payment must be received in the CP Sport Office by the closing date of the competition, no late entries will be accepted under any circumstances.

Personal best performance details must be entered as of 31st March 2016

New to Athletics -Athletes new to athletics or trying a new discipline please fill in details below of the best distance/ time achieved in training. This must be signed by the coach or teacher who can confirm your results.
Name / Surname
Date
Discipline 1 / Time/ Distance recorded
Discipline 2 / Time/ Distance recorded
Athletics Club / Coach/ teacher
Coaches/ teacher signature
Athletes Signature

(If new to athletics or to the discipline please fill in the new to athletics form below)

Event / Date / Venue / Time / Distance
1:
2:
3:
4:

Rules of Cerebral Palsy Sport Athletics Series 2016

Athletes must be aged 11yrsand above old by 31st December 2016to enter the Athletics Series.

Athletes aged 8 -10yrsold by 31st December 2016can enter the 60m and Howler throw in selected venues only.

Entry Forms must be received in the CP Sport Office by the closing date of the competition, no late entries will be accepted under any circumstances. *Separate payment fee for the National Athletics Championships

Athletes wishing to be eligible for the end of season trophies must compete in at least two out of the four meetings, the best 2 individual performances will determine the overall winners in each category. Please see our website for more details. Please note due to no funding we will not be awarding prize money but each winner will receive a trophy.

Athletes’ performances will be measured against personal best performances as of the 31st March 2016 andmustbe entered on the application form. If we do not have this information we will be unable to enter you into the series.

CP Sport Senior over 20’s CP Sport Junior under 20’s:
Male Track Athlete Male Track Athlete
Female Track Athlete Female Track Athlete
Male Field Athlete Male Field Athlete
Female Field Athlete Female Field Athlete

Guest Track: Guest Field:
Overall Guest Track Athlete Overall Guest Field Athlete

Most improved Guest :( not in series) Colin Rains Award:
Male and Female athlete Overall athlete

Event: Registration Fee:

*Separate payment fee for National Athletics Championships

Membership details - Why not take advantage of our membership scheme?

Already a member – EnterMembership Number ______

To benefit from CP sport members discount I wish to apply for: (please √ appropriate box)

Annual Membership – Adult Member £15

Annual Membership – Junior Member (19 yrs and under)£10

Paymentshould accompany the application form (please tick you selected method of payment)

Donations

Cerebral Palsy Sport relies on the kindness of people like you to help fund a programme of sporting events and activities for children, young people and adults with cerebral palsy. If you would like to make a donation to support more people with cerebral palsy to reach their potential through sport please tick box and state amount you would like to donate. Thank you.

I would like to help by donating £…………… to Cerebral Palsy Sport.

I understand that I must have paid or will pay an amount of Income Tax and/or Capital Gains Tax in each tax year, that is at least equal to the tax that Charities & Community Amateur Sports Clubs (CASCs) I donate to will reclaim on my gifts. I understand that other taxes such as VAT and Council Tax do not qualify and that CP Sport will reclaim 25p of tax on every £1 that I give. If a UK taxpayer please tick here.

Cerebral Palsy Sport Athletics Series 2016
Competition date / Venue / Closing Date
Saturday 4th & Sunday 5th June 2016 / Stoke Mandeville Stadium
Guttman Road
Stoke Mandeville
Bucks HP21 9PP / Friday 13th May 2016
Saturday 25th June 2016 / Doncaster Athletic Club
Keepmoat Athletic Stadium
Stadium Way
Doncaster, DN4 5JW / Friday 3rd June 2016
Saturday 13th & Sunday 14th August 2016 / Stoke Mandeville Stadium
Guttman Road
Stoke Mandeville
Bucks HP21 9PP / Friday 22nd July 2016
Sunday 28th August 2016 / Gateshead International Stadium, Neilson Road, Gateshead
NE10 0EF / Friday 5th August 2016
National Athletics Championships 2016
Saturday 24th September 2016 / Harvey Hadden Sport Complex
Wigman Road, Bilborough, Nottingham, NG8 4PB / Friday 2nd September 2016

Photographic/Media Consent Form

Dear Participant / Parent / Guardian,

Thank you for helping us.

At Cerebral Palsy Sport we produce a variety of different materials which we use to inform people, charitable trusts and other relevant organisations about the work that we do. Occasionally these materials will include photographic images or videos of participants, the surrounding areas and on occasion parents and guardians. We use these materials to enhance our promotions and to illustrate the variety of work we achieve.

We also use images from our events on our website, through our social media channels, such as Facebook and Twitter (these will only ever be used by the official Cerebral Palsy Sport accounts), and in leaflets and other promotional materials which may include our printed publications; adverts; audio visual and electronicmaterials; media work; display materials; social media and any other media we may use in the future.

From time to time we may also allow use of photographic images and videos by third parties. These third parties will only be those with an official association with Cerebral Palsy Sport, such as a corporate partner or funder.

Please complete the form below, selecting carefully how you give your consent, to enable us to use these images and any personal information you supply alongside the images (such as a name, age and disability) to actively promote the work of Cerebral Palsy Sport.

The images will not be used for any other purpose.

Your details:

Name of participant / Surname
Name of Parent/ Guardian (under 18yrs old only) / Surname
Address
Postcode
Telephone
Email
I consent to the use of photographic images or video footage for use by Cerebral Palsy Sport only / Yes / No
I consent to the use of photographic images or video footage for use by third parties officially associated with Cerebral Palsy Sport / Yes / No
Please state here if there are any ways in which you do NOT want us to use photo(s) of you:
Signed
or type if emailed / Date

Data protection statement

Other than as specified above, the information that you give us here will only be used to contact you about these photo(s). We will not pass the details recorded on this form on to any other organisation without your permission.

For internal use only:
Name of event
Location of event / Date
Image reference(s)
Contact name / Contact phone number

IMPORTANT NOTICE:

Spectators (including parents, relatives and coaches) - spectatorswishing to use photographic / film / video equipment with a telescopic or zoom lens should register their intent with the promoter of the event by completing a self-declaration form

Unit 5, Heathcoat Building, Nottingham Science & Technology Park, University Boulevard, Nottingham, NG7 2QJ.

Telephone: 0115 925 7027. Email:

Find out more about the work of CP Sport at

A Limited Company registered in England and Wales, no 04181593. Registered office as shown. Registered Charity No: 1088600