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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 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