Presenting the

2007

PANTHER INDOOR CHALLENGE

Sportshall Athletic Competitions

open to all disabled people from 11 to 99 years

Team and Individual Competitions

In the spirit of UKA Sportshall Rules

Sunday, 30th September 2007

12 noon to 4pm

Northgate Sports Centre, Ipswich

 

Entry: £2 per athlete. 

Complete the form overleaf and for more information contact

Mike Oakley, Chairman – Orwell Panthers – 01728 747681

www.orwellpanthers.co.uk

 

Meeting Sponsors include

and


Entry form for the 2007 – Panther Challenge – 30th September 2007

 

Name

 

 

Sex

Male / Female *

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

County

 

 

 

 

 

 

Postcode

 

 

Date of Birth

 

 

 

School

 

 

Club or Team

 

 

 

Nature of Disability

Moderate Learning Difficulty

Severe Learning Difficulty

 

 

 

(Circle as appropriate)

Physical

Ambulent

Wheelchair Manual / Electric *

 

 

 

 

Visual

Hearing

Other (specify)

 

 

 

 

Emergency Contact

 

 

 

 

 

Name

 

Relationship to athlete:

 

 

 

 

Home Phone

 

Mobile

Parent/ Guardian/ Carer/ Friend *

 

 

 

Medical information (Disclose only if relevant)

 

 

 

 

 

Inhaler

Yes / No *

* Delete as appropriate

 

 

 

Medication being taken:

 

 

 

 

 

 

Allergies:

 

 

 

 

 

 

GP Name

 

Phone Number

 

 

 

 

 

 

 
                                                         

Photographs are sometimes taken at our activities for publicity purposes. If you do not want the athlete to be featured in this way please tick the box  [   ]. 

For athletes under 18, the signature of a parent/guardian/carer is required to give permission for the athlete to attend and compete and to agree to staff taking any medical action deemed necessary in the unlikely event of an accident.

All information given will be held in strictest confidence and used only for the purpose of the event.

 

NAME……………………………………   SIGNATURE ……………………………………

Relationship to athlete:  PARENT / GUARDIAN / CARER (Delete as appropriate)

 

This form must be completed and returned with the entry fee of £2 payable to Orwell Panthers A. C. to:

 

Mike Oakley, 8 Meadowside, Wickham Market, Woodbridge , Suffolk , IP13 0UD .

Click below to download printable copy