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Independance Day Vault Competition
DATE
:
TIME:
1:00 pm
LOCATION
:
New Heights Gym
1
Phone:
337-365-3806
Fax:
337-367-0652
Website:
http://www.newheightsgym.org/
Email:
leleux@mindspring.com
DIRECTOR
:
Shane LeLeux
337-359-7314
EQUIPMENT
:
·
120’ Runway
·
21’ x 24’
·
Gill Athletics Standards
ENTRY FEE
:
· $25 per vaulter if paid by June 25 (includes tshirt) · $35 per vaulter if paid after June 25 or on site (includes tshirt)
Mail Entries to
:
New Heights Gym
AWARDS
:
Top 5 vaulters in each category will receive a specialized medal!
T-SHIRTS
:
T-shirts and concessions will be sold on site.
T-shirts purchased on site will cost $15.
T-Shirts Design
Medals Design
REGISTRATION FORM
Name:
_________________________ Gender:
M / F
Age: _____
Phone:
______________ Email:
________________________
Address:
____________________________________________
USATF #:
_________
Club Affiliation:
__________________
PR:
_______
Shirt Size: ________
Division (circle one): Open Youth (12 & Younger) Girl / Boy
Youth (13 – 14)
Girl / Boy
Intermediate (15 – 16)
Girl / Boy
Young (17 – 18)
Women
/ Men
Open Adult (19 +)
Women
/
Men
RELEASE OF CLAIMS
It is my understanding that there are certain risks involved with participating in the pole vault.
In recognition of the possible dangers connected with pole vaulting and any physical activity, I hereby knowingly and voluntarily waive and right of cause of action of any kind whatsoever arising as a result of such activity, from which any liability may or could accrue to Shane LeLeux, Bridget LeLeux, New Heights Gym, and its officers, agents, employees, or instructors.
If under eighteen (18) years of age, parent or legal guardian must sign.
__________________________________________________________________
Print Name of Athlete
Signature of Athlete
Date
________________________________________________________________________________________
Print Name of Parent/ Guardian
Signature of Parent/ Guardian
Date
Mail Completed Entry Form, USATF membership number, and Release with Entry Fee to:
New Heights Gym
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