Name: _________________________________________________________________ Birth Date:______________ Age:_______
(First) (Last)
Address:________________________________________________________________________________ E-Mail ______________
(Street) (City) (State) (Zip)
Phone: (H)______________________________________ (W)______________________________________ Male___ Female___
In Case of Emergency Contact:
Name:_______________________________________________ Phone:(H) _____________________ (W)____________________
T-Shirt - Circle Size: Medium Large Extra Large Extra,Extra Large
Men golfers indicate handicap: ______________ Bowlers, please list your most recent average:_______________
Bowlers, please list the people you want to bowl on the same lane with:_____________________________________
PRINT THIS FORM AND THE EVENT APPLICATION BELOW, FILL IT OUT, AND MAIL WITH
ENTRY FEE TO: OZARK SENIOR OLYMPICS - 2725 N. Westwood Blvd. - Poplar Bluff, MO. 63901
Entry Fee: $20.00 for 3 events or less - $30.00 for 4 or more events
PARTICIPANT WAIVER AND RELEASE OF LIABILITY
In consideration of being allowed to participate in OZARK SENIOR OLYMPICS athletics sports program and
activitie, the undersigned:
Agrees that prior to participating they each will inspet the facilities and equipment to be used, and if they believe anything is unsafe, they will immediately advise their coach or supervisor of such condition(s) and refuse to participate.
Acknowledges and fully understands that each participant will be engaging in activities that involve risk of serious injury,
including permanent disability and death, and severe social and economic losses which might result not only from own
actions, inactions or negligence but the actions, inactions, or negligence of others, the rules of play, or the condition of
the premises or of any equipment used. Further, that there may be other risks not known to us or reasonably foreseeable
at his time.
Assumes all the foregoing risks and accepts personal responsibility for the damages following such injury, permanent
disability, or death.
Releases, waives, discharges and covenants not to sue OZARK SENIOR OLYMPICS, its affiliated clubs, their respective
administrators, directors, agents, coaches, volunteers, and other employees of the organization, other participants,
sponsoring agencies, sponsors, advertisers, and, if applicable, owners and leasees of premises used to conduct the
event. All of which are hereinafter referred to as "Releasees" from any and all liability to each of the undersigned, his
or her heirs and next of kin for any and all claims, demands, losses or damages on account of injury, including death or
damage to propery, caused or alleged to be caused in whole or in part by the negligence of the releasee or otherwise.
THE UNDERSIGNED HAS READ THE ABOVE WAIVER AND RELEASE, UNDERSTANDS THAT HE/SHE HAS GIVEN UP
SUBSTANTIAL RIGHTS BY SIGNING IT AND SIGNS IT VOLUNTARILY.
Signature:_____________________________________________________________________________________ Date:_________________________
2009 OZARK PHYSICAL THERAPY,LLP
SENIOR OLYMPICS EVENTS & EXHIBITS
Please CHECK the events you wish to enter. WE WILL NOT ACCEPT ANY LATE ENTRIES.
YOU WILL BE ELIGIBLE TO ENTER ONLY THE EVENTS YOU SELECT ON THIS APPLICATION.
Please check the event schedule and do not enter events with conflicting times.
__________ DINNER
__________ Extra Ticket ($10.00)
POWER LIFTING
__________ Bench Press
__________ Dead Lift
__________ Leg Press
__________ Arm Curl
BASKETBALL
__________ Free Throw
__________ Around the World
__________ BILLIARDS
BOWLING
__________ Singles
__________ Doubles (Partner/age) ____________
__________ Mixed (Partner/age) ______________
DARTS
__________ Mens
__________ Womens
__________ ONE MILE FUN WALK*
__________ GOLF
__________ HORSESHOES
__________ SCRABBLE & CHECKERS
__________ WASHER PITCHING*
SHUFFLEBOARD (2 Events)
__________ Singles
__________ Doubles (Partner/age) ____________
__________ FOOTBALL THROW - Distance*
__________ FOOTBALL THROW - Accuracy*
__________ FIELD GOAL KICK*
__________ SOFTBALL THROW - Distance*
__________ SOFTBALL THROW - Accuracy*
__________ SOCCER KICK*
__________ HOOLA HOOP*
* Fun Events *
Please make a copy of the events so you will know the event and time.
