Please Refer to the Accompanying Information BEFORE Completing This Form

Form D: Entry form for INDIVIDUAL Competitors for DSE EMids Regional on 9th May (Please refer to the accompanying information BEFORE completing this form) Entries close on Friday 2nd May 2014

Name of Athlete: Male/Female:

Club/School/Group: (Please give name of person completing form for athletes under 18):

Home Address :

E-mail address: (print clearly please)

Mobile (or landline) Tel contact number:

Date of Birth: Age on 9th May:

Disability Category - if TWO or more impairments please state all below. IPC Classification (if known) eg T20 or F33: Or Disability Code eg 3f or 4d (see separate sheet): EVENT ENTRY DETAILS FOR ATHLETE Tick EVENT PERSONAL NOTES Event(s)# BEST Long Jump For those who cannot take part in running long *Standing Long Jump jump due to severe disability or age 8-11 Indoor* Discus IPC classified athletes to use IPC weights Turbo* Javelin IPC classified athletes to use IPC weights Rubber* Shot IPC classified athletes to use IPC weights *Javelin *Seated Throw or IPC classified ambulant only *Club *Seated Throw only *Bean Bag Height Throw *Seated Throw only *Club/Grip Ball *Power Chair Users only *Coordination/ Precision Event *Power Chair Users only *50m *Power Chair Users only

*60m (restricted entry) * Must have suitable frame / use manual day chair 100m Ambulant and Racing wheelchair 200m Ambulant and Racing wheelchair *400m *Ambulant athletes only *1500m *Ambulant athletes only Wheelchair Slalom Power & Manual Wheelchair users only #MAXIMUM OF THREE EVENTS FOR ATHLETES (POWERCHAIR USERS MAY ENTER ALL 4 AVAILABLE EVENTS) Post (with payment of £4 made payable to LDADG): LDADG, c/o Cherie D’Silva, 41 Highcroft Avenue, Oadby, Leics LE2 5UH Also (to help speed up the admin) Email (with attachment): [email protected] Signature (must be from Parent/Guardian named above if Athlete is under 18): ______

Leicestershire Disability Athletics Development Group Leicestershire Disability Athletics Development Group