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First Name                              Last Name                                   Sex                   WASUSA Number
             M F                 

Address 1                                                Address 2                                              City                                              ST      ZIP           
   

Date of Birth (MM/DD/YY)                                             Age Group       Athlete Contact E-Mail
                       U 11 14 16 18 20 23   Archery N/C 7-9 10-12 13-14 15-17 18-20 21-22   

Team                                                                   Coach / Guardian                                                  
       

Telephone #              First NJDC?          SCI DISABILITY   SCI CAUSE               SCI OTHER (EXPLAIN)            
     Check If Yes          TRAUMATIC CHRONIC    CAR ACCIDENT DIVING FALL SPINA BIFIDA CANCER OTHER   

Track           Class      0 51 52 53 54     20m   40m  60m  100m  200m  400m  800m  1500  5000m

Field            Class      0 51 52 53 54 55 56 57    Softball  Club  Discus  Javelin  Shot Put

Swimming    Class   S 0 1 2 3 4 5 6 7 8 9 10 SB 0 1 2 3 4 5 6 7 8 9 10 SM 0 1 2 3 4 5 6 7 8 9 10               F25            F50              F100             F200         F4/500
                                                                                              BK25          BK50           BK100          BK200  
                                                                                              BRST25      BRST50       BRST100      BRST200 
                                                                                              FLY25        FLY50         FLY100         FLY200 
                                                                                              IM75           IM100         IM150            IM200   

Archery      Class   0 W1 RECURVE W1 COMPOUND W1 BOW STAND RE-CURVE W1 BOW STAND COMPOUND W2 RECURVE W2 COMPOUND W2 BOW STAND RECURVE W2 BOWSTAND COMPOUND  

Powerlift    Class    0 M49 M54 M59 M65 M72 M80 M88 M97 M107 W41 W45 W50 W55 W61 W67 W73 W79 W86