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					   All Ability Challenge Cup 2011
    Essex Athletics Open Event
        For all people with disabilities from 8 to 99 years

                      Team and Individual Competitions
                       Within the Spirit of UKA Rules

                        Saturday, 16th April 2011

    10 am to 4 p.m. (finishing time is an approximation)

    Venue: Mark Hall Athletics Track, Mark Hall Sport
         Centre, London Road, Harlow, CM17 9LR

  Events: Long Jump / Distance Club / Shot / T Javelin / Grip Ball / 60m /
100m / 200m / Relay / Boccia / plus a 800m Manual Wheelchair Guest Event


               Entry: £4 per athlete (under 18 yr olds)
                          and £6 per athlete (18 +)

                           Closing Date: 24th March 2011

To take part please complete and return the entry form on the reverse of this Flyer
Teams are asked to bring a minimum of 2 volunteer officials to help with this event.
Volunteers would be warmly appreciated on the day to assist with a variety of tasks.


    For more information contact : Helen Offord, Community & Leisure Policy Officer,
            Harlow Council 01279 446417 Email : helen.offord@harlow.gov.uk
                        With Funding Support from Essex Legacy
   Challenge Cup 2011 - 16th April 2011               - Team Registration Form – (for
   Team managers to complete, as applicable)

Name of Club / School ______________Name of Team Manager _________________
Name of Team Official/s ________________________________________________
Tel No: _______________ Mobile No: ________________Email:________________

Please enclose £4.00 per person under 18 and £6 per person if 18 and over, Please make
cheques payable to All Ability Sports & Leisure. Return this form with individual consent
forms (see page 4) to: AAS&L c/o Helen Offord, Leisure Services, Harlow Council, Civic
Centre, The Water Gardens, Harlow, CM20 1WG
Fee enclosed : ____________(Please make cheques payable to All Ability Sports & Leisure)


            Name of Athlete         Age      M/F   Disability Description   Disability
                                                                            Category
                                                                            (See page 3)
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                    ALL ABILITY CHALLENGE CUP 2011 ATHLETICS



                                   CATEGORY OF DISABILITY

Category      Possible Conditions                          Description
   0       No disability
    1      Electric or manual Wheelchair    Poor sitting balance. Poor trunk control.
           User (Cerebral Palsy             Extremely hard to move unaided.
           Quadriplegia)                    Poor control in four limbs.
                                            Difficulty in gripping objects.
                                            Great difficulty in moving around on
   2       Manual Wheelchair User           Can have poor sitting balance.
           (Cerebral Palsy, Paraplegia      Slight or good leg movement (with some hip
           Polio, Spina Bifida, Amputee)    movement).
                                            Leg amputee who competes in a wheelchair.
                                            May have very slight weakness in arms.
   3       Ambulant Cerebral Palsy          Able to walk aided/unaided.
                                            Can use crutches or other support.
                                            Difficulty in controlling all four limbs.
                                            When running the child looks floppy.
                                            May be effected in all limbs.
   4       Ambulant Cerebral Palsy          Can only balance unaided on one leg.
                                            Affected on one side.
                                            Seen to have a limp when walking / running.
   5       Ambulant Cerebral Palsy          Able to walk well but one side may look weaker.
   6       Ambulant Amputee                 Above or below knee amputee (either single or
                                            double leg).
                                            Arm amputee (either single or double arm).
   7       Ambulant Blind or visually       Blind or visually impaired athlete who can
           impaired                         compete on their own or who may require
                                            assistance or guiding during activities.
   8       Dwarf                            Dwarf
   9       Learning Disabilities            To include Severe Learning Disability, Profound
                                            and Multiple Learning Disabilities.
  10       Learning Disabilities            To include Moderate Learning Disability.


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Challenge Cup 2011 All Ability Athletics Open 2011 – Individual Consent Form

Date: 16h April 2011. Time: 10am to 4pm (finishing time is an approximation)

Venue: Mark Hall Sport Centre, London Road, Harlow,CM17 9LR.

This form must be completed and returned with the entry fee of £4 under 18 or £6 for 18 +
payable to All Ability Sports & Leisure, c/o H. Offord, Sports Development Officer, Leisure
Services, Harlow Council, Civic Centre, The Water Gardens, Harlow, CM20 1WG. Tel No 01279
446417 Email helen.offord@harlow.gov.uk Fee enclosed __________________

 Name                                                          Male / Female *

 Address

 County                                                    Postcode

 Date of Birth                                             Age             E mail:

 School                                                    Club or Team

 Disability Category
 (See page 2)
 Emergency contact details:


 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

  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.
     Relationship to athlete: PARENT / GUARDIAN / CARER (Delete as appropriate)
     NAME…………………………………………….. SIGNATURE ……………………………………………………
Please return entry form by the closing date 24th March 2011
 ‘Harlow Council undertakes that it will treat any personal information (that is data from which you can be
identified, such as your name, address, e-mail address, etc.) that you provide to us, or that we obtain from
you, in accordance with the requirements of the Data Protection Act 1998. The personal information
collected on this form is used for the purpose of processing your application for the Challenge Cup 2011.
The information will also be used for evaluation and monitoring purposes to compile statistics for use by
Harlow Council and its partners i.e. ECC & sportengland. These statistics will not include any information that
will identify you as an individual. This information will be retained for a maximum of 3 years’.
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