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KTCCCA Indoor State Pole Vault ChampionshipsFebruary 25, 2018 Whelan-Nault Vault Center
237 Bonniemere Rd Shelbyville Ky
Parking will be at
Shelbyville Christian Church2375 Frankfort Rd, Shelbyville, KY 40065There is a walkway from the church to the
Vault Center.Do not bring busses up
Bonniemere.
MASTERS & OPEN ENTRY
FORMName_____________________ Sex M F 2018 USATF
#_________________________Email address___________________________
Birthdate (Month, day, year)_________________ Contact Patty Rouse Prouse23@windstream.net to
see if your age has previously been verified or for more information on USA
Track & Field membership as well as club membership. Events (circle maximum of four) 55H 55 dash 1600
400 800 200 Shot Put High Jump Long Jump Triple Jump, 1500 Racewalk. Pole Vault
(to be held Sunday, February 25 at Kentucky Elite Athletics, Shelbyville)Athletes Release: In consideration of your
acceptance of my entry into the Kentucky USATF Track & Field Indoor
Championships, I voluntarily agree to participate in the KTCCCA Indoor
Championships and knowingly assume any and all risk of loss, damage, property
loss, injury (including death), both foreseen and unforeseen, of my attendance
at and participation in the Kentucky USATF Indoor Championships from any cause
whatsoever. I, for myself, my heirs, personal representatives and assigns do
hereby release, waive, discharge and covenant not to sue USA Track & Field,
Inc., Kentucky Elite Athletics, the Kentucky USATF Association, Mason County
High School, Kentucky Track & Cross Country Coaches Association and the
Mason County Board of Education in which the Kentucky USATF Indoor
Championships are held (collectively Releases) from all liability, loss,
claims, demands, possible causes of action, court costs, settlement costs and
fees, attorneys fees and any other expenses arising from any claim or lawsuit
that may arise from any loss, damage or injury (including death) to me or my
property resulting from or arising in connection with, or related to, my
attendance at or participation in the Championships. I/we grant permission to
the Meet Directors or their designee or the assigned Chaperones of any USA
Track & Field competition or program to act as guardian/spokesman with full
authorization and power to authorize emergency medical treatment, including
hospitalization and anesthesia, if medically necessary, for me while in route
to/from or at the site of the KTCCCA Indoor Championships, competition or
program. I/we understand that should a health emergency arise, I/we will be
notified but if/we cannot be reached by phone such medical treatment as is
deemed necessary by medical personnel under the circumstances presented is
hereby expressly authorized._________________________________________________
________________________________________________________Signature - ATHLETE Signature - PARENT / GUARDIAN(Must be signed if athlete is under 18 years of
age.)Telephone:
(_________)_____________________________List allergies and current medications:
________________________________________________
10:00 AM Masters/Open1:30 High School Girls Class A, AA, AAA will
vault together, scored separately March 3 in the team championships 3:30 High School Boys Class A, AA, AAA will vault
together, scored separately March 3 in the team championships Please note: athletes can vault only in one
division. They cannot vault both the open and the high school division. USATF
memberships are required for the open/masters division.Coach and/or school representative must be
present for athletes to compete in the high school division.Limited seating is available. You may want to
bring you own lawn chair. Admission will be $5.00NOTE-Entry Pole Vault deadline February 20. Entry
fee $20 per athlete pre-registered, $30 race day fee. Kentucky USATF Indoor
Championships Mail to KTCCCA c/o Frank Miklavcic 319 Erin Way Frankfort, Ky
40601