Fill in Form and Submit.                                                                    < CLICK ON WHEN COMPLETE.

First Name                              Last Name                                   Sex              FULL MEMBER WASUSA Number
             M F                 

Address 1                                                Address 2                                                City                                                         ST        ZIP           
          

Date of Birth (MM/DD/YY )         Age Group                LAST GRADE COMPLETED           E-Mail
          U 14 16 18 20 23                         6 7 8 9 10 11 12 SOME COLLEGE        

Team                                                                Coach / Guardian                                                  
       

Emergency Contact                                           Relationship                                                             Emergency Reachable Phone Number
               

Cell Telephone #                  First NJDC?    DISABILITY                                            
      Check if Yes        SCI TRAUMATIC SCI CHRONIC CP Other Cause: CAR ACCIDENT DIVING FALL SPINA BIFIDA CANCER OTHER    Other Specify

WHICH TRACK AND ROAD EVENTS ARE YOU COMPETING IN  (CHECK OR UNCHECK ALL THAT APPLY):

Track           Class      0 31 32 33 34 51 52 53 54     EVENTS TRACK: 20m   40m  60m  100m  200m  400m  800m  1500  1mile  2mile 5000m
                                                                            ROAD:  5K   10K  15K  1/2MARATHON MARATHON

Although wheelchair racers span all distances which do you consider yourself best at: Sprint Middle Distance Long Distance

Your clinic registration is NOT complete until the medical history and medical release forms are completed and received as apart of the NJDC registration package at the games office.