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The Burke Rehabilitation Hospital - wheelchair app 04

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The Burke Rehabilitation Hospital - wheelchair app 04
Name ____________________________________________________________ Male ________
Female_________
Address ____________________________________________________________________________________________
City ____________________________________ State_____________ Zip____________________________________
Home Number ( ) _______________________ Work Number ( )________________________________________
Date of Birth _____________________________ Age as of 1/1/04 ___________________________________________
Is this your fi rst time competing?
Yes
No
Coach's Name ___________________________________ Team Affi liation ____________________________________
WSUSA/NDSA Classifi cation:
Track
Track
Track
Field
WSUSA or NDSA Membership No._________
Athlete Signature:
Date:
Parent/Guardian Signature:
Date:
Fee Schedule
:
$15 by September 15th
$20 after September 15th
Registration deadline: Sept. 25
Registration deadline: Sept. 25
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, ad min is tra tors, and assigns, waive and release any
and all claims against Tri-State Wheelchair Athletic As so ci a tion, 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 October 2, 2004.
Events may be photographed and vid eo taped. Please notify us in advance if you do not wish to be photographed or videotaped.
(if minor)
Athlete Signature:
Athlete Signature:
Parent/Guardian Signature:
Parent/Guardian Signature:
Last
Address ____________________________________________________________________________________________
Address ____________________________________________________________________________________________
Address ____________________________________________________________________________________________
Address ____________________________________________________________________________________________
First
Address ____________________________________________________________________________________________
Address ____________________________________________________________________________________________
Address ____________________________________________________________________________________________
Address ____________________________________________________________________________________________
Middle
Address ____________________________________________________________________________________________
Address ____________________________________________________________________________________________
T-Shirt size:
(circle one) Adult: S M L XL XXL Children: M
The Burke Rehabilitation Hospital
2004 WHEEL CHAIR GAMES
October 2, 2004
Wheelchair Sports, USA has sanctioned fi eld and table tennis events.
You may compete in a max i mum of three fi eld events + slalom + track & table tennis
.
Field
FUTURES (6 and under)
Club
Softball
Slalom
40 Meters
60 Meters
100 Meters
JUNIOR
JUNIOR Division A (7-9 yrs)
Club
Softball
Shot put (F3-F8)
Slalom
60 Meters
100 Meters
400 Meters (T3-T4)
Turbo Javelin
JUNIOR
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____________________
Classifi cation______________
(TT 1- TT 8)
Novice___________________
Intermediate_______________
Advanced_________________
Wheelchair Player__________
Standing Disabled__________
*Table tennis will run concurrently
with fi eld events. Minimum of 10
registered athletes needed to
hold event.
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
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
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
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





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