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					                                                    2011 Marine Corps Trials Registration




                                 Marine Corps Trials REGISTRATION REQUEST***
                                                    All-Marine Wounded Warrior Sports
From:
To:   Commanding Officer, Wounded Warrior Regiment
Subj: Registration Request for 2011 Marine Corps Trials & Warrior Games

Date:
I request to participate in the Marine Corps Trials 18-27 February 2011 in Camp Pendleton, CA. If I am one of the
50 Marines selected to the 2011 All-Marine Warrior Games team, I request to represent the Marine Corps at the
Warrior Games training camp and competition 1-22 May 2011 in Colorado Springs, CO.
INSTRUCTIONS:
A. Fill out form completely. Incomplete registration requests will not be accepted
B. Please indicate N/A for any questions that do not apply to veterans
C. Complete Medical Questionnaire
D. Return Registration Request, Medical Questionnaire, & DD214 (required for veterans) to WWSports@usmc.mil or fax to 703-432-1869
E. Receipt confirmation will be acknowledged within 48 business hours via email or phone. If you do not receive confirmation in this time, please
email WWSports@usmc.mil or call 703-432-1850
1. Last Name, First Name                                2. Rank             3. Date of Birth           4. FULL SSN




5. Are you on active duty? (If    6. Are you retired from the               7. If no for questions 5 & 6, please indicate date and type of
yes, indicate EAS)                military? (If yes, indicate # yrs         discharge.
      Y      N                    service & date retired)

                                      Y     N

10. Hometown (city & state)                     8. List primary medical insurance & policy #.        9. List secondary medical insurance &
                                                                                                     policy #.




11. Home Email:                                                             12. Work Email (if applicable):




13. Mobile Phone / Do you use text msg?         Y      N                         15. Current Mailing Address



14. Work Phone (if applicable)



20. Parent Command (Complete address)                              21. Current Duty Station (Complete address)                    22. Airport
                                                                                                                                  you will fly
                                                                                                                                  from:




23. Your Supervisor (Name & Phone)                                 24. Primary S-1 POC (Name & Phone)


                                                                   25. Secondary S-1 POC (Name & Phone)


26.   GENDER 27. Height               28. Weight             29.      Do you require a non-   If yes, who do you have in    30. Do you require an
                                                                       medical attendant?                mind?              ADA-compliant room?
  M        F
                                                                       Y       N                                                 Y       N




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                                                   2011 Marine Corps Trials Registration




16. Primary Emergency POC (Name, Phone, Relationship)                                  18. Are you a member of Team Semper Fi?        Y   N


17. Secondary Emergency POC (Name, Phone, Relationship)                                19. Are you a member of Operation Rebound (CAF)?
                                                                                                                    Y       N
31. Do you have a GTCC          33. Hand                                    Polo         T-Shirt     Warmup      Warmup       Shorts      Shoe Size
(gov't credit card)?            (circle)      34. Sizes (circle each)                                  Top       Bottom
                                                                             S              S           S           S           S

         Y        N                Right          Women's Sizes              M              M           M           M           M
                                  Handed
32. Do you have a                                                            L              L           L           L            L        ________
personal credit card?
                                   Left             Men's Sizes             XL             XL           XL          XL          XL
                                  Handed
         Y        N                                                         XXL            XXL         XXL         XXL          XXL
35. Have you participated in previous Wounded Warrior USMC-hosted camps? If so, what and when?




  36.    Select Events (maximum of 2 INDIVIDUAL sports, no maximum on number of events within sport, no
                                      maximum on number of team sports)
                        Archery (circle one)
                (choose Compound OR Recurve, cannot do both)                              Wheelchair Basketball (team)

                      Compound Open (all disabilities)

                       Recurve Open (all disabilities)
                                                                                                Sitting Volleyball (team)


                  Shooting (circle max of 2)                                                       Cycling (circle one)
                  10-meter Air Pistol (Open) - 40 shots
                                                                              10K Handcycle MEN (lower mobility impairment/amputee
                  10-meter Air Pistol (SH1) - 40 shots
                                                                                      that prohibit one from riding 2-wheel upright bike
             10-meter Air Rifle Standing (Open) - 40 shots

             10-meter Air Rifle Standing (SH1) - 40 shots                   20K Recumbent MEN (upper mobility, orthopedic and/or
                                                                            balance problems that prohibit one from riding a 2-wheel
             10-meter Air Rifle Standing (SH2) - 40 shots                                  upright bike or handcycle

              10-meter Air Rifle Prone (Open) - 40 shots
                                                                            10K Handcycle/Recumbent/Bicycle WOMEN (Open to all
               10-meter Air Rifle Prone (SH1) - 40 shots                           disabilities - *factored race with interval starts based on
                                                                                                          disability group)
               10-meter Air Rifle Prone (SH2) - 40 shots
                                                                                   30K Bicycle MEN OPEN (no permanent physical
                       Shooting Categories
                                                                                        disability - i.e. PTSD, TBI, Orthopedic)
    Open - no permanent physical disability (PTSD, TBI, Ortho, etc)

  SH2 - upper body impairment - competitors who have no ability to           30K Bicycle MEN Permanent Physical Disablilty (i.e.
support the weight of the firearm with their arms and, therefore, require
                             a shooting stand
                                                                            amputation - *factored race with interval starts based on
                                                                                                 disability group)
        SH1 - all other competitors with permanent physical disability


                                                                               30K Tandem Men/Women/Mixed Visually Impaired
                                                                             (visual acuity of 20/200 or greater in both eyes and/or a
                                                                                        visual field of less than 20 degrees)




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                                        2011 Marine Corps Trials Registration




                         Field
            Men's Shotput (Standing) - 6 kg


              Men's Shotput (Sitting) - 4 kg                 Track Upper Body Amputee / Limb Dysfunction / VI (UB)
            Men's Discus (Standing) - 1.5 kg                                    Men's 100-meter dash


              Men's Discus (Sitting) - 1 kg                                     Men's 200-meter dash

           Women's Shotput (Standing) - 3kg                                     Men's 800-meter dash

            Women's Shotput (Sitting) - 3kg                                 Women's 100-meter dash
Track Single & Double Below Knee Amputee (BK, DBL BK)
                                                                            Women's 800-meter dash
                 Men's 100-meter dash

                                                                    Track Wheelchair Racers (WC)
                 Men's 200-meter dash
                                                                                Men's 100-meter dash
                 Men's 800-meter dash
                                                                                Men's 200-meter dash
               Women's 100-meter dash
                                                                                Men's 800-meter dash
               Women's 800-meter dash
                                                                            Women's 100-meter dash
Track Single & Double Above Knee Amputee (AK, DBL AK)
                                                                            Women's 800-meter dash
                 Men's 100-meter dash

                                                              Track Open - no permanent phys disability (PTSD, etc)
                 Men's 200-meter dash                                           Men's 100-meter dash

                 Men's 800-meter dash                                           Men's 200-meter dash

               Women's 100-meter dash                                           Men's 800-meter dash

               Women's 800-meter dash                                       Women's 100-meter dash

                                                                            Women's 800-meter dash




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                                                2011 Marine Corps Trials Registration




                Swimming Single Leg Amputee                                    Swimming Above Elbow Impairment / Amputee
                      Men's 50-meter Freestyle                                                Men's 50-meter Freestyle

                     Men's 100-meter Freestyle                                               Men's 100-meter Freestyle

                     Men's 50-meter Backstroke                                               Men's 50-meter Backstroke

                    Women's 50-meter Freestyle                                              Women's 50-meter Freestyle

                   Women's 50-meter Backstroke                                             Women's 50-meter Backstroke

               Swimming Double Leg Amputees                                     Swimming Below Elbow Impairment / Amputee

                      Men's 50-meter Freestyle                                                Men's 50-meter Freestyle

                     Men's 100-meter Freestyle                                               Men's 100-meter Freestyle

                     Men's 50-meter Backstroke                                               Men's 50-meter Backstroke

                    Women's 50-meter Freestyle                                              Women's 50-meter Freestyle

                   Women's 50-meter Backstroke                                             Women's 50-meter Backstroke

              Swimming Spinal Cord Injury (SCI)                            Swimming Open (visually impaired / no perm disability)

                      Men's 50-meter Freestyle                                                Men's 50-meter Freestyle

                     Men's 100-meter Freestyle                                               Men's 100-meter Freestyle

                     Men's 50-meter Backstroke                                               Men's 50-meter Backstroke

                    Women's 50-meter Freestyle                                              Women's 50-meter Freestyle


                   Women's 50-meter Backstroke                                             Women's 50-meter Backstroke

37. List sports experience or achievements during the past three years. Use space on back if necessary.




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                                                  2011 Marine Corps Trials Registration




38. When were you injured? How? If applicable, which unit were you with when you became wounded, ill, or injured?




39. What personal sport equipment, if any, will you bring with you? (e.g. archery bow, basketball wheelchair, bicycle, handcycle, pistol, racing
wheelchair, recumbant bicycle, rifle, shooting jacket, etc.)




40. Specify injury or illness (e.g. above/below knee, above/below elbow, PTSD, SCI, TBI, etc.)




41. Why do you want to participate?




                                                             Privacy Act Statement
    Authority to request this information is derived from 10 USMC 5031, the purpose of which is to assist in the identification and selection of
     individuals qualified to train for higher levels of sports competition. This information will be used by the Wounded Warrior Regiment in
    determining those individuals with the highest qualifications for further training and competition. However, if requested information is not
                                   provided, individuals concerned may not be selected for this training/competition.




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                                                      2011 Marine Corps Trials Registration




                                                        AFFIDAVIT AND CERTIFICATIONS
   I certify that all the information and data provided is correct and true and that I have read and understand the Privacy Act Statement. It is
 understood that this application must go through my chain of command as well as my Primary Care Physician. I understand that all information
   may be subject to verification, and if false, my registration will not be considered for participation. I understand I must travel with adequate
medication required for the duration of training & competition. I agree to be photographed and cooperate with the public affairs representatives in
                      positively representing the Marine Corps. If I am a veteran, I certify that I have been honorably discharged.


                               Signature of Applicant                                                                Date

                                                       COMMANDING OFFICER'S ENDORSEMENT

    To: Wounded Warrior Regiment                               From:
         Attn: WARP, MCT / WG
         1998 Hill Ave
         Quantico, VA 22134-5103
         703-432-1874/1870


     1 Approved              1 Disapproved

 By approving this request, I support Marine applicant in participating in the Marine Corps Trials 18-27 February 2011 in Camp Pendleton, CA,
and, if selected, at the Warrior Games training camp / competition 1-22 May 2011 in Colorado Springs, CO. I understand the funding for this trip
                                                 will be borne by the Wounded Warrior Regiment.


    Date                       Typed name and grade of Unit Commander                                       Signature


                                                      PRIMARY CARE PHYSICIAN ENDORSEMENT
Name:                                  Phone:                                        Installation:                          Email:



Physicians, please indicate injury category(ies)

___ Single Leg Amputee (BK)                  ___ Single Leg Amputee (AK)                              ___ Double Leg Amputee (BK)

___ Double Leg Amputee (AK)                 ___ Below Elbow Amputee (BE)                              ___ Above Elbow Amputee (AE)

___ Leg Impairment (BK)                     ___ Leg Impairment (AK)                                   ___ Arm Impairment (BE)
               (Permanent)                                     (Permanent)                                      (Permanent)

___ Arm Impairment (AE)                  ___ Spinal Cord Injury (SCI)                                ___ Post Traumatic Stress Disorder
              (Permanent)

___ Traumatic Brain Injury (TBI)             ___ Visual Impairment                                    ___ Other: ____________________
                                          (Corrected visual acuity of 20/200 or greater)                                 (Temporary orthopedic, etc.)

Physical limitations: (additional comments on other side if necessary):




 I have reviewed this application and the attached medical questionnaire. I verify that the named individual is qualified physically and mentally to
   train or compete in USMC or higher level competitions. I further attest that the named individual will have adequate medication supply for the
                                                                  dates indicated.

    Date                       Printed name of Primary Care Physician                                       Signature




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