2013 powerade state games of north carolina individual swimming

2013 POWERADE STATE GAMES
OF NORTH CAROLINA
INDIVIDUAL SWIMMING ENTRY FORM
The individual entry fee for swimming is $25 regardless the number of events entered (8 max, but no more than 4 per day).
Competition starts at 8:00 a.m. each day for morning sessions. The pool will open for warm -ups at 6:45 a.m.
Competition starts no earlier than 1:00 p.m. for aft ernoon sessions. Warm-ups will start no earlier than 12:00 p.m.
The entry deadline for this sport is Wednesday, June 19. Fill out the form completely including the Event Name/Division at the
bottom. Be sure to sign the Agreement to Participate (or have a Parent or Legal Guardian sign if under 18) on the back of the form or your
registration will not be accepted.
PARTICIPANT INFORMATION – PLEASE TYPE OR PRINT CLEARLY
(
) ________ - ___________
______________________________________ ______________________________
Day Phone
Last Name
(
First Name
) ________ - ___________
Evening Phone
____________________________________________________________________
Mailing Address
__________________________________________________________
City
DOB_____ - _____ - _____
Month Day Year
_________________
Zip Code
______ ____
Age* Sex
________________________________
County
E-mail Address [email protected]__________________________
Team Name: __________________________________________________________________
*Note: Please give your age as of the first day of your competition.
PERSON TO CONTACT IN CASE OF AN EMERGENCY
(
) ________ - ___________
______________________________________ ______________________________
Day Phone
Last Name
(
First Name
) ________ - ___________
Evening Phone
Meet Approval Info
Recognized by LMSC for NC for USMS, Inc, Recognition #
Enter Swimming Events: 4 Max per day (See page 4&5 for list of events)
Events
Seed Time
1._______________________________________________
2._______________________________________________
3. _______________________________________________
4. _______________________________________________
5. _______________________________________________
6. _______________________________________________
7. _______________________________________________
8. _______________________________________________
___________
___________
___________
___________
___________
___________
___________
___________
Make check payable to
State Games of NC
Entry fee
$__25__
Please consider a taxdeductible donation
when you register. $________
Total Enclosed
$________
ENTRANT MUST READ AND SIGN THE AGREEMENT TO PARTICIPATE ON THE NEXT PAGE OR THE ENTRY WILL
BE RETURNED
(Parent or legal guardian must sign if the entrant is under 18 years old.)
ATHLETE AGREEMENT TO PARTICIPATE FORM
In consideration of being allowed to participate in any way in the POWERADE STATE GAMES OF NORTH CAROLINA athletic/sports
program and its related events and activities, the undersigned acknowledges, appreciates, and agrees that:
1. The risk of injury from the activities involved in this program is significant, including the potential for permanent paralysis and death,
and while particular rules, equipment, and personal discipline may reduce this risk, the risk of serious injury does exist; and,
2. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE
NEGLIGENCE OF THE RELEASEES or others, and assume full responsibility for my participation; and,
3. I willingly agree to comply with the stated and customary terms and conditions for participation. If however I observe any unusual
significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the
nearest official immediately; and,
4. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE AND HOLD
HARMLESS NORTH CAROLINA AMATEUR SPORTS, their officers, officials, agents and/or employees, other participants,
sponsoring agencies, sponsors, advertisers, and, if applicable, owners and lessors of premises used to conduct the event (“Releasees”),
WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH or loss or damage to person or property, WHETHER
ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE.
X___________________________________________
PRINTED NAME OF PARTICIPANT
X________________________________________________________
PARTICIPANT’S SIGNATURE DATE
FOR PARTICIPANTS OF MINORITY AGE
(UNDER AGE 18 AT TIME OF REGISTRATION)
This is to certify that I, as parent/guardian with legal responsibility for this participant, do consent and agree to his/her release as provided
above of all the Releasees, and, for myself, my heirs, assigns, and next of kin, I release and agree to indemnify the Releasees from any and
all liabilities incident to my minor child’s involvement or participation in these programs as provided above, EVEN IF ARISING FROM
THEIR NEGLIGENCE.
X
PARENT/GUARDIAN’S SIGNATURE
EMERGENCY PHONE #
DATE