Pasadena Senior Olympics Official Entry Application

Pasadena Senior Olympics 2003 OFFICIAL ENTRY APPLICATION APPLICATION DEADLINE: JUNE 2 & 9, 2003 _________________________________________________________      ____ Female First Name                       Last Name               Age (as of 12/31/03)    Birthdate   ____ Male _____________________________________________________________________ Street Address                                             City                                  State                Zip _______________________________________________________          Telephone _______________________________________________     M___L___XL___XXL___ Emergency Contact (Name and Telephone)                                             T-Shirt Size E-Mail Address: __________________________________ I will attend the following special events: __ Celebration of Athletes (6/14 - $8) __ Power Lifting Clinic (6/21) __ Bar-B-Que (6/29) ARCHERY       #1 - 10 ___ 300 Round ($8) #11 - 20 ___ American 900 Round ($8)            NAA - Olympic: ___ Recurve ____ Compound Fingers ___ Compound Release            NFAA: ___ Freestyle ___ Freestyle Limited ___ Bowhunter            ___ Bowhunter Freestyle ___ Bowhunter Freestyle Limited ___ Barebow           ___ Traditional BADMINTON      #31 ___ Singles ($10)                             No Registration Fee Required.                                #32 ___ Doubles ($10/person)                  Partner: _______________                                #33 ___ Mixed Doubles ($10/person)       Partner: _______________ BASKETBALL     #58 ___ Free Throw ($5)            #59 ___ Precision Shooting ($5)                                  #60 ___ 3-On-3 Team ($59/team)                                  Please submit Team Roster Form with entry. BILLIARDS          #61 ___ 8 Ball ($12) BOWLING            #62, 64, 66 ___ Scratch                                #63, 65, 67 ___ Handicap - Average: _____            ___ Singles ($7)            ___ Doubles ($9/person)                  Partner: _________________________            ___ Mixed Doubles ($9/person)       Partner: _________________________ CYCLING       ($5 per event, plus $3 for parking at El Dorado Park)                                  Time Trials: #68 ___ 5K #69 ___ 10K                                       #70 ___ 10K Tandem #71 ___ 10K Recumbent FUN RUN/WALK                #143 ___ 5K (3.1 Miles) ($5)                              No registration fee required. GOLF                     #72 __ Scratch ($60)   #73 __ Handicap ($60)   Index # (as of 5/03): __                                                                              Partner: _________________________                                                                              Partner: _________________________                                                                              Partner: _________________________ HORSESHOES          #79 ___ Singles ($5) InLINE SKATING        #78 ___ .6 Mile TT ($5)              #77 __ 1.6 Mile TT ($5)                                         #76 __ 3.2 Mile RR ($5)            #75 ___ 6.4 Mile RR ($5) LAWN BOWLING    #80 ___ ($5)                              No registration fee required. POWER LIFTING     #81 ___ Bench Press ($5)            Weight __________ POWER LIFTING (50-59)     #40 ___ Bench Press ($5)            Weight __________ RACE WALK         #85 __ 800M Unjudged ($5) #86 __ 1,500M ($5)    #87 __ 5,000M ($5) RACQUETBALL      #88 ___ Singles ($12)                                  #40 ___ Doubles ($12/person)        Partner: _________________ ROPE CLIMB          #90 ___ ($10) SHUFFLEBOARD    #91 ___ Singles ($10 for 1 event, $15 for both/person)                                       #92 ___ Doubles         Partner: _____________________                                       No registration fee required. SOCCER                  #35 - 36 ___ ($99/team)                                       Please submit Team Roster Form with entry. SOFTBALL            #140-142, 146 __ ($204/team)                                        #139 (San Gabriel Valley) ___($150/team)                                        Please submit Team Roster Form with entry. SWIMMING            ___ Advanced & Novice Divisions ($5/event)                                  Please submit separate Application. TABLE TENNIS       #115, 116, 117 ___ Advanced (Rating of 1000 and over)                                  #82, 83, 84 ___ Novice                                  ___ Singles ($5)                                  ___ Doubles ($5/person)                   Partner: ________________                                  ___ Mixed Doubles ($5/person)         Partner: ________________ TENNIS            #119 ___ Singles ($12)                                 #120 ___ Doubles ($12/person)        Partner: _____________                                 #121 ___ Mixed Doubles ($12/person)    Partner: _____________ TRACK & FIELD ($5/event)    #122 ___ 50M     #123 ___ 100M     #124 ___ 200M     #125 ___ 400M     #126 ___ 800M     #127 ___ 1,500M     #128 ___ 5,000M          #133 ___ Pole Vault       #130 ___ Javelin     #132 ___ Long Jump       #131 ___ Shot Put            #134 ___ High Jump        #129 ___ Discus       #135 ___ Softball Throw     #145 ___ Grandparent/Grandchild Relay (NC) VOLLEYBALL       #136 - 138 ___ ($89/team)                                   Please submit Team Roster Form with entry.            Total Event Fees                                    $ _______    Make checks payable and mail to:            Registration Fee                                    $ _26.00_              Pasadena Senior Center            ___ #Celebration Tickets @ $8           $ _______                   85 East Holly Street            ___ #Extra Bar-B-Que Tickets @$8   $ _______                   Pasadena, Ca. 91103            ___ Senior Games Donation               $ _______            ___ Late Fee                                         $ _______                   Credit Card Payments:                       TOTAL ENCLOSED:                $ _______        ___ Visa  ___ MasterCard                                                                              Card No.: ________________                                                                              Expiration Date: ___________                                                                              Signature: _______________ Release of Liability PHOTO & FILM WAIVER: I hereby grant full permission to the organizers, their agents, employees, and representatives to use my name, voice, and/or picture or film in any broadcast, telecast, advertising, promotion or other use in relation to the Pasadena Senior Olympics. LIABILITY WAIVER: I, the undersigned participant, hereby agree to indemnify and hold harmless the organizers of the Pasadena Senior Olympics ("PSO"), hereinafter sometimes referred to as sponsors, their agents, employees, and representatives and assigns, from any and all actions or claims of whatsoever kind or nature which I or my representatives or assigns may have or at any time in the future have due to any injury or property damage arising out of my participation in the PSO. I understand and agree that any dispute over injury or property damage caused by myself or another participant must be settled between the individuals. I warrant and represent to the organizers that I have prepared myself for the event(s) which I have entered by practicing the same prior to my participation. I warrant and represent that I am in good physical health and condition, am physically able to compete in the event(s), and know of no physical restriction whatsoever which would prohibit my participation in the PSO. I have been advised by the organizers that it would be in my best interest to consult a physician prior to my preparation for and participation in this event. I recognize and understand that the preparation and competition may necessitate strenuous physical activity and could possibly activate an unrecognized pre-existing cardiovascular disorder which I may have, thereby resulting in serious or life-threatening physical harm to me. The organizers have my permission to have a physician treat me during my participation in the PSO. Signature ______________________________________    Date ________________