Name ____________________________________________________________ Male
Female
Address ___________________________________________________________________________________________
City ____________________________________ State_____________ Zip___________________________________
Home Number ( ) _______________________ Work Number ( )________________________________________
Date of Birth _____________________________ Age as of 1/1/05 ___________________________________________
Is this your first time competing?
Yes
No
Coach's Name ___________________________________ Team Affiliation ____________________________________
Telephone ___________________________________
WSUSA/NDSA Classification:
Track
Field
WSUSA or NDSA Membership No._________
Athlete Signature:
Date:
Parent/Guardian Signature:
Date:
Fee Schedule
:
$15 by September 10th
$20 after September 10th
REGISTRATION DEADLINE: SEPT. 15TH
Please make checks payable to:
Burke Wheelchair Games
785 Mamaroneck Avenue, White Plains, New York 10605
(914) 597-2850 www.burke.org
In consideration of acceptance of this form, I/We hereby for ourselves, heirs, administrators, and assigns, waive and release any
and all claims against Tri-State Wheelchair Athletic Association, Burke Rehabilitation Hospital and all its related corporate
entities, for all injuries and expenses incurred by me/us at The Burke Rehabilitation Hospital Wheelchair Games held in White
Plains, New York on September 24, 2005.
Events may be photographed and videotaped. Please notify us in advance if you do not wish to be photographed or videotaped.
(if minor)
Last
First
Middle
T-Shirt size:
(circle one) Adult: S M L XL XXL Child: M
NO ONSITE REGISTRATION
The Burke Rehabilitation Hospital
2005 WHEELCHAIR GAMES
September 24, 2005
You may compete in a maximum of three field events + slalom + track & table tennis
.
FUTURES (6 and under)
Club
Softball
Slalom
40 Meters
60 Meters
100 Meters
JUNIOR Division A (7-9 yrs)
Club
Softball
Shot put (F3-F8)
Slalom
60 Meters
100 Meters
400 Meters (T3-T4)
Turbo Javelin
JUNIOR Division B (10-12 yrs)
Club
Softball (F1-F2)
Shot put (F2-F8)
Discus
Javelin (F3-F8)
Slalom
60 Meters
100 Meters
400 Meters
800 Meters
1500 Meters (T3-T4)
ADULT MASTER
Discus
Club
Javelin
Shot put
Slalom
100 Meters
400 Meters
800 Meters
1500 Meters
*If you are over age 50, please
select the division in which you
prefer to compete.
TABLE TENNIS*
Open____________________
Classification______________
(TT 1- TT 8)
Novice___________________
Intermediate_______________
Advanced_________________
Wheelchair Player__________
Standing Disabled__________
*Table tennis will run concurrently
with field events. A minimum of 10
registered athletes are needed to
hold event. 40mm orange balls will
be used.
Power chairs are NOT eligible to
compete in 800 and 1500 meter
track events.
We reserve the right to cancel
events due to lack of enrollment.
JUNIOR Division C (13-15 yrs)
Club (F1)
Softball (F1)
Shot put (F2-F8)
Discus
Javelin (F2-F8)
Slalom
60 Meters (T1-T2)
100 Meters
400 Meters
800 Meters
1500 Meters
JUNIOR Division D (16-18 yrs)
Club (F1)
Softball (F1)
Shot put(F2-F8)
Discus
Javelin (F2-F8)
Slalom
60 Meters (T1,T2)
100 Meters
400 Meters
800 Meters
1500 Meter
s
JUNIOR Division E (19-21 yrs)
Club (F1)
Softball (F1)
Shot put(F2-F8)
Discus
Javelin (F2-F8)
Slalom
60 Meters (T1,T2)
100 Meters
400 Meters
800 Meters
1500 Meters
