Individual Event Entry Form West Virginia Amateur
2007
CROSS COUNTRY CHAMPIONSHIPS
November 3, 2007 10:00 am Coonskin Park/Charleston, West Virginia
Complete this form and submit with entry fee $5.00 per athlete (non-refundable). Payment must be made payable to: Capital City Striders, Inc./Post Office Box 1243/Charleston, WV 25325
All runners must have current AAU Card and/or USATF Card. Year 2008 cards can be purchased with the entry for $15.00 for AAU youth runners and $20.00 for USATF membership. Note: Except for signature, please PRINT or TYPE all information.
NAME: Last _____________________________________ First __________________________ Middle Initial __________
ADDRESS: ________________________________CITY: _____________________ STATE: _______ZIP CODE: ________
E-Mail address: ____________________________________
Club Name (if none, leave blank) _______________________________ Association: West Virginia Region Number: 5 or VI
Membership Card Number(s) Card Type (USATF or AAU or Both)
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Athlete’s Release: In consideration of this entry being accepted, I/we shall be legally bound and do release for myself, heirs, executors, and administrators any claim for loss, injury or damage which may occur during participation in or traveling to and from this event and do hereby release Capital City Striders, Inc., WV AAU, Kanawha County, Coonskin Park, meet officials and others assigned from any claim. I/we grant permission to the Meet Directors, Coaches, and Chaperones to act upon this athlete as a guardian/spokesperson in granting permission for the use of emergency medical treatment, including anesthesia, if necessary. I understand that should a medical emergency arise, an attempt will be made to notify, but that authorization is hereby granted.
A copy of the proof of age and an AAU membership number must be provided with the official entry.
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Signature - PARENT, GUARDIAN
Telephone: Home ( ) ________________ Work ( ) ____________________
List allergies and current medication(s): ______________________________________________________________________________
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Athletes who participate in this competition may be subject to formal drug testing in accordance with USA Track & Field Regulation 10 and IAAF Rule 55. Athletes found positive for banned substances, or who refuse to be tested, will be disqualified from this event and will lose eligibility for future competitions. Some over-the-counter medications contain banned substances. Information regarding drugs and drug testing may be obtained by calling the USOC hot line at 800-233-0393.
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Age Divisions (please circle appropriate group and birth date) Bantam Boys (born 1997 & later) Bantam Girls(born 1997 & later) Midget Boys (born 1995 - 1996) Midget Girls(born 1995 - 1996) Youth Boys (born 1993 - 1994) Youth Girls (born 1993 - 1994) Inter.Boys (born 1991 - 1992) Inter.Girls (born 1991 - 1992) Young Men (born 1989 - 1990) Young Women (born 1989 – 1990) Birth Date: |__________|_________|__________| Month Day Year |
Top twenty (20) individuals quality for AAU Nationals, December 2, 2007 in Virginia Beach, Virginia.
Top twenty-five USATF individuals quality for Regional held November 18, 2007 in Springfield, Ohio. Regional qualifiers (top 12) compete in the USATF National Championships, December 8th in Lawrence, Kansas.
NOTE: Please be sure you have completed ALL information.
Proof of Age: Birth certificate, certified Baptismal Record, Passport, Driver’s License, or U.S. Military Identification must be attached.