<p> 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</p><p>Name of Athlete: Male/Female:</p><p>Club/School/Group: (Please give name of person completing form for athletes under 18): </p><p>Home Address : </p><p>E-mail address: (print clearly please) </p><p>Mobile (or landline) Tel contact number: </p><p>Date of Birth: Age on 9th May:</p><p>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</p><p>*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): ______</p><p>Leicestershire Disability Athletics Development Group Leicestershire Disability Athletics Development Group </p>