2018 Senior Games of Indiana Registration Form

NAME: *

First Name Last Name

ADDRESS: *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

PHONE NUMBER: *

- Area Code Phone Number

GENDER:

Male Female

EMAIL: *

example@example.com

AGE (Please circle one): *

55-62 63-70 71-78 79-86 87 and Over

Do you wish to compete for the title "Oldest Male" or "Oldest Female" participant? To be eligible you must compete in one medal competition. If so, provide your birth date (month, day, year):

*

Yes No

Date of Birth: *

EMERGENCY CONTACT

NAME: *

First Name Last Name

PHONE NUMBER: *

- Area Code Phone Number

INDIVIDUAL EVENT REGISTRATION

Registration fee is $15.00 per person (add $2 for 2X or 3X shirts)- payable upon registration. Please place a checkmark in the box beside each event in which you would like to participate. Please try to keep your commitment to participate at each event you register for. This will assist us a great deal when ordering meals.

Monday, June 4

Opening Ceremonies/Bingo: 9:00-10:00 a.m. Dance Contest: 10:00-11:30 a.m. Lunch: 11:30 a.m.-12:30 p.m. Bowling: 1:00-4:00 p.m.

Tuesday, June 5

Miniature Golf/Lunch: 8:00 a.m.- 12:30 p.m. Toss'Em: 1:30-4:00 p.m.

Wednesday, June 6

Pickle Ball: 9:00 a.m.- 12:00 Noon Lunch: 11:00-12:00 Noon Nine Lap Walk: 1:00-3:00 p.m. Four Lap Walk: 1:00-3:00 p.m. Frisbee Golf Demonstration: 3:30-5:00 p.m.

Thursday, June 7

Basketball Toss: 9:00-11:00 a.m. Lunch: 12:00-3:00 p.m. Cards & Checkers: 12:00- 3:00 p.m.

Please select one if you are participating in Cards & Checkers: *

Friday, June 8

Closing Ceremonies Remarks: 10:00-10:30 a.m. Sponsor Fair/ DJ: 10:30-11:15 a.m. Lunch: 11:15- Noon Closing Ceremonies Awards: 12:00-1:00 p.m.

Official 2018 Senior Games t-shirts MUST be worn at all events-including the Dance Contest. As with any rule...here's the exception...Closing Ceremonies does not require your 2018 Senior Games t-shirt. The shirts are available on a first come, first served basis.

PLEASE SELECT THE SIZE YOU WOULD PREFER: *

The deadline for Registration is May 11th. T-shirts will be available for pick up May 7-25 at LifeSpan Resources, Inc., P.O. Box 995, 33 State Street, (3rd Floor), New Albany, IN, 47150.

Phone 812-948-8330 or 1-888-948-8330.

Information on any additions or substitutions will be given to you when you pick up your t-shirt. You will also receive an updated schedule of events and an identification badge.

I hereby agree for myself, my executors, administrators, and assigns to indemnify and hold harmless all sponsors, officials and persons, and agencies connected with the 2018 Area 14 Senior Games of Indiana from all claims for damages arising in connection with my participation in the Senior Games.

I have prepared myself for the events that I have entered by practicing prior to the Senior Games. To the best of my knowledge and belief. I have no physical restrictions which would prohibit my participation in the events I have selected. I have been advised by the sponsors of the Senior Games that it would be in my best interest to consult my physician in regard to participation in the Senior Games. Sponsors and officials have my permission to have a physician attend me if it is deemed necessary during my participation in the Senior Games.

I also hereby give my permission to the sponsors of the Senior Games to use my name and/or picture in any newspaper, broadcast or any other account of the event without remuneration to me.

*

I AGREE

Signature (Use left mouse button to sign):

Clear

Print Name:

Doctor's Name:

Date:

Do you require any special assistance? *

Yes No

TRANSPORTATION

If you are in need of transportation through the Lifespan Transportation program, there will be a fee of $4.00 per round trip. To schedule your rides please indicate below that you need a ride and Transportation will contact you after May 11th to schedule. Ride availability is limited and will be provided on a first come first served basis.

Are you in need of transportation to your Senior Games events? *

Yes No

Do you only need transporation to the Miniature Golf Event? *

Yes No

DONATIONS

Please Select One:

Friend- $10 Patron- $25 Partner- $50 Champion- $100

In Honor of:

In Memory of:

Your name as it should appears in the SG Program

I wish to remain anonymous.

Please make checks payable to LifeSpan Resources, Inc. P.O. Box 995, New Albany, IN 47151 by April 23, 2018, to be included in the Senior Games Program Book or by May 11, 2018, to be included in the Loved One's Book.

These donations are not included as a part of your Registration Fee.

Schedules, registration forms, and various other information are available on our website. www.lsr14.org