Athlete's First Name:
Athlete's Last Name:
Gender:	-- Male Female
Birth Date:  (MM/DD/YYYY)	-- 01 02 03 04 05 06 07 08 09 10 11 12 -- 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 -- 1995 1996 1997 1998 1999 2000
Home Address:
City:
State:
Zip:
Phone:
Shirt Size:	-- Youth L S M L XL
Parent's E-mail Address:

 

***Note: The Age of the athlete is calculated on 12/31/2009!!!***

 

Event #1	Event #2	Event #3
-- 50m Dash 9-10 yr old only 100m Dash 200m Dash 400m Dash 9-12 yr old only 800m Run 11-14 yr old only 1600m Run 13-14 yr old only Standing Long Jump Softball Throw 4x100m Relay	-- 50m Dash 9-10 yr old only 100m Dash 200m Dash 400m Dash 9-12 yr old only 800m Run 11-14 yr old only 1600m Run 13-14 yr old only Standing Long Jump Softball Throw 4x100m Relay	-- 50m Dash 9-10 yr old only 100m Dash 200m Dash 400m Dash 9-12 yr old only 800m Run 11-14 yr old only 1600m Run 13-14 yr old only Standing Long Jump Softball Throw 4x100m Relay

 

If participating in a relay, please provide the names of the relay members.

 

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The above named participant and the participant's parent/guardian have requested registration of the participant in the Hershey youth Program. In consideration of such registration, the right of the participant to compete in the Hershey Youth Program and the use by the participant of the sponsoring agency's facilities and equipment, both the participant and the parent/guardian each acknowledge that the participant of the sponsoring agency's facilities and equipment, both the participant and the parent/guardian each acknowledge that the participant will be competing in the Hershey Youth Program and sponsoring agency's facilities at the participant's sole risk and the participant, on his or her own behalf and on the behalf of his or her heir, executors, administrators and assigns hereby release, discharge and agree to hold harmless The Hershey Company and its franchises and the National Recreation and Park Association, USA Track & Field and Athletics Canada. We understand that those participants who advance to the state/provincial level and are winners at this level do not automatically advance to the regional level for the North American Final Meet. This is covered under Rule 9, Article 1 in the rule book. We also agree to allow the Hershey Youth Program to use and reproduce the participant's name and/or likeness and/or information concerning the participant and to circulate the same for any and all purposes in any manner. We certify that the information on this participation form is correct.