Athlete Entry Form

  First Name

  Last Name

  Street Address    City  

   Zip

  Parish     DOB  Month/Day/Year

  School   Grade

Area Code 318 337 225 504 985 Choose         Home Phone

   Email address if you have one

Coach Name   Choose Caucasian African American Hispanic Asian Native American Other Race      

Choose 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Choose   Age on day of race (5-21)

Bantam Junior Senior Choose   Division    Male Female Choose Sex/Gender      Disability

Small Medium Large X-Large XX-Large   T-shirt size  Yes No Choose   Wheel Chair Use?  Choose 1a 1b 2 3 4 5 6 7 8 9 V1 V2 V3 V4   Track Classification

Choose 1a 1b 2 3 4 5 6 7 8 9 V1 V2 V3 V4 Field Classification            Medical Insurance Company

  Medical Policy#    Medicaid # if applicable

  Emergency Contact Name

  Phone # of the Emergency Contact Person

Track events entered, check all that apply:  maximum of five total events and the 800m (if qualified) may be entered.

20m Electric  20m 60m Electric 60m 100m 200m

400m  800m Slalom

Field events entered, check all that apply

Precision Toss  Soft Shot  Discus  Shot Put  Softball (Bantams only)

Competition Site(s)  Choose Shreveport New Orleans Alexandria Shreveport & New Orleans Shreveport & Alexandria New Orleans & Alexandria All Three

Comments (optional):