Senior High a Home Designed Form U La by dzf19760


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									                                                                                                                                                                                                                QUALIfyING SITE
    EVENT                                            CHECK IN / START TIME                                SITE
                                                                                                                                                                                                               fOR THE 2011 STATE
                                                     WEDNESDAy, MAy 4                                                                                                                                          SENIOR GAMES fOR
                                                                                                                                                                                                                THE fOLLOWING
    MARKSMANSHIP                                         8:00 AM      8:30 AM      LAFAYETTE SHERIFF’S TRAINING ACADEMY
    Sponsored by Lafayette Sheriff’s Dept.                                         337-236-5665
    (Lunch provided by Prudhomme Tax Services.)
                                                                                                                                                                                                                BOWLING (singles)
    DIRECTIONS: From Evangeline Thruway at Willow Street (new Home Depot site), go east on Willow St. for 1.5 miles to Teurlings Drive. Turn
    left and go over the tracks, take first right on Lajaunie Road. Follow Lajaunie Road until the T, about 1 mile. Turn right on Woodpecker Road                                                                 DANCE TEAM
    and go about 2 tenths of a mile. Turn left on Michael Allen Road (gravel), follow to Training Academy.                                                                                                           DISCUS
                                                      THURSDAy, MAy 5                                                                                                                                             HORSESHOES

    BAIT CASTING                                         9:00 AM      9:30 AM      ROBICHEAUX CENTER POOL                                                                                                          (advanced)
                                                                                   1919 ERASTE LANDRY ROAD                                                                                                           JAVELIN
    CROQUET                                             12:30 PM 1:00 PM           ROBICHEAUX CENTER                                                                                                                SHOT PUT
                                                                                   1919 ERASTE LANDRY ROAD                                                                                                       SHUffLEBOARD

C                                                        fRIDAy, MAy 6                                                                                   National                                                 TABLE TENNIS
    BILLIARDS - 8 BALL                                   8:30 AM      9:00 AM      STICKS BILLIARD PARLOR                                              Senior Games                       24th ANNUAL                (singles)
    Sponsored by Sticks Billiards Parlor                                           3220 Johnston St., 337-989-1727                                      Association                                             HAMMER THROW
    DANCE TEAM COMPETITION/                              6:00 PM      6:30 PM      THOMAS PARK                                                        Acadiana District Games is a
                                                                                                                                                                                       ACADIANA DISTRICT
H                                                                                                                                                                                        SENIOR GAMES
    CELEBRATION Of ATHLETES                                                        300 Geraldine St.                                                sanctioned member of Louisiana
                                                                                                                                                                                                                (Ages 40-49 eligible
    Complimentary meals and drinks sponsored                                                                                                          Senior Olympic Games, Inc.                               to participate in Track
    by District Attorney, Mike Harson, Humana
                                                                                                                                                                                                                  & Field, Golf, and
                                                        MONDAy, MAy 9                                                                                                                                                Swimming)
                                                                                                                                                                                         LAfAyETTE, LA
    HORSESHOES                                           8:30 AM      9:00 AM      DUPUIS CENTER
    SHUffLEBOARD                                        12 NOON 12:30 PM           1200 E. Pont Des Mouton
                                                                                   Corner of Pont Des Mouton & Louisiana Avenue
                                                                                                                                                                                     APRIL 16 - MAy 10, 2011
                                                       TUESDAy, MAy 10
                                                                                                                                                                                     REGISTRATION DEADLINE
                                                                                                                                                                                        MARCH 18, 2011
    THROWS (Football, Frisbee, Softball)                 8:30 AM                   DUPUIS CENTER
                                                                                   1200 E. Pont Des Mouton
    WASHER PITCH                                         9:30 AM                   Corner of Pont Des Mouton & Louisiana Avenue
    BASKETBALL fREE THROW                               10:30 AM                                                                                                                         SPONSORED BY:
    BEAN BAG BASEBALL (Teams)                                FOLLOWS
     Charmin Toss
                                                               ALL DAY
     Wii Games

    Sponsored by AAA Home Health, Junior
    League of Lafayette, Humana


    Permit No. 515                                                                          Lafayette, LA 70508
     Lafayette, LA                                                                          160 Industrial Parkway
     U.S. Postage                                                                           Lafayette Council on Aging
    Non-Profit Org.                                                                         ACADIANA DISTRICT SENIOR GAMES
                        GENERAL INfORMATION fOR                                                                                            ACADIANA DISTRICT SENIOR GAMES
                     ACADIANA DISTRICT SENIOR GAMES                                                              PACKET PICK-UP: Each Acadiana Registered Participant will pick up their Packet at the site of their first event (sport).
                  COORDINATOR: JODy THIBODEAUX, 337-262-5990                                                                                               - KEEP THIS SCHEDULE -

I                             INfORMATION fOR ALL ENTRANTS
    ELIGIBILITy: The Acadiana District Senior Games are open to anyone who is at least 50 years of age
                                                                                                                             IMPORTANT: AVOID CONfLICTS By CHECKING START TIMES!
                                                                                                                             *Starred Events are qualifying events for the 2011 State Championship Games.
           by December 31, 2011. Athletes, who are first time participants, are required to submit proof
           of age with the entry/registration form. The Acadiana games are an OPEN event. Out-of-state             EVENT                                   CHECK IN / START TIME                        SITE

N          residents are eligible and encouraged to participate. All competitors must have their entry
           forms to the Lafayette Council on Aging office by March 18, 2011. All participants must be
                                                                                                                                                           SATURDAy, APRIL 16

                                                                                                                   OPENING CEREMONIES                          7:30 AM    8:00 AM   UL TRACK & FIELD COMPLEX
           registered to participate. Out of District/State must finish in the top 3 to receive an award.                                                                           Cajundome Boulevard
           Age division for doubles will be determined by the age of the youngest partner. The 2011

F          Acadiana District Games is a qualifying site for State Senior Games.                                    DAN MESTAyER MEMORIAL                        7:30 AM   8:00 AM   UL TRACK & FIELD COMPLEX
                                                                                                                   ACADIANA SENIOR TRACK and fIELD                                  Cajundome Boulevard
                                                                                                                   Sponsored by Junior League of Lafayette, ULL

    DATES: APRIL 16 - MAY 10, 2011
                                                                                                                   BADMINTON                                   1:30 PM    2:00 PM   THOMAS PARK
                                                                                                                   TABLE TENNIS                                                     300 Geraldine St.

    ENTRy DEADLINE: MARCH 18, 2011
                                                                                                                                                            SUNDAy, APRIL 17
    fEES: Entry fee is $25.00 for first 3 sports: EXAMPLE - Badminton, Golf, Track & Field (3 sports).
          ADDITIONAL SPORTS: $3.00 each.                                                                           SWIMMING
                                                                                                                   Sponsored by Crawfish Aquatics
                                                                                                                                                              12:30 PM 1:00 PM      CRAWFISH AqUATICS (formerly Susan’s Swim),
                                                                                                                                                                                    Susan St.                                               H
                                                                                                                   (formerly Susan’s Swim Club)                                     Behind Lafayette High School
    DOUBLES / MIXED DOUBLES: Partners need to submit their entry forms in the same envelope.
                                                                                                                                                             fRIDAy, APRIL 29

    WEATHER POLICy: Sports using outdoor sites are weather dependent. Competitions will be conducted               BOWLING SINGLES*                           8:30 AM     9:00 AM   LAFAYETTE LANES
         unless an Acadiana Senior Games official determines weather conditions to be potentially                  Sponsored by Lafayette Lanes and                                 2825 Johnston St.

         dangerous or life threatening, or if the playing fields would incur significant damage.                   Lafayette Women’s Bowling Association                            South College Shopping Center
         IMPORTANT: In checking your sports, be sure that you avoid conflicts of times in each sport
         checked. All times stated are starting times. SPORTS ARE IN BOLD PRINT.                                   TENNIS*                                    12:30 PM 1:00 PM      DUPUIS CENTER

    GUESTS: Family and friends are welcome to attend all sporting events free of charge.                                                                   SATURDAy, APRIL 30
                                                                                                                                                                                    1200 E. Pont Des Mouton
A   DISTRICT GAMES are designed to make available additional competition in athletic events already
                                                                                                                  PICKLE BALL doubles / mixed doubles         8:30 AM     9:00 AM   BOURGEOIS HALL, UL LAFAYETTE
                                                                                                                                                                                    225 Cajundome Blvd.

                                                                                                                  Sponsored by ULL
          being held at the state level. Each district will not offer all 72 sport categories available at the
          state games. Athletes must qualify in one of the 2011 District Games to compete in the 2011             BENCH PRESS*                                2:00 PM     2:30 PM   RED’S

          State Championship Games in the following events: *Bowling Singles (top three scratch score             Sponsored by Red’s Health Club                                    301 Doucet Rd., 337-984-7738
          places); *Men & Women Golf (must meet minimum standard); *Advanced Horseshoes (top three                                                            MONDAy, MAy 2

          places); *Table Tennis Singles (top three places); *Advanced Shuffleboard, *Discus, *Javelin
                                                                                                                   MINIATURE GOLf                             10:00 AM 10:30 AM     KART RANCH
          and *Shot Put (top two places); *Dance Team Competition (two age groups, all teams qualify).
                                                                                                                   Sponsored by Kart Ranch                                          Hwy. 89 / Old Youngsville Hwy.
          Athletes may also qualify by meeting minimum qualifying standards for each starred event.

                                                                                                                   Sponsored by Jewel Specialty & Supply Co.
                                                                                                                                                             8:00 AM      8:30 AM   JAY & LIONEL HEBERT MUNICIPAL GOLF COURSE
                                                                                                                                                                                    1121 Mudd Ave.

           NO REfUNDS AfTER MARCH 18, 2011 DEADLINE                                                                and DataCom

                                                                                                                                                              TUESDAy, MAy 3

                                  friday, May 6, 6:00 p.m. at Thomas Park
                                                                                                                   BOUREé                                      8:30 AM    9:00 AM   DUPUIS CENTER
                                                                                                                                                                                    1200 E. Pont Des Mouton

                                                                                                                   TEXAS HOLD ‘EM                             12:30 PM 1:00 PM      DUPUIS CENTER
                                                                                                                   Sponsored by Airway Home Medical                                 1200 E. Pont Des Mouton

N                   For information about the State Championship Games to be held in October 2010, contact:
       Jody Thibodeaux, Dircector of local LSOG District Office                 The LSOG State Office
            160 Industrial Parkway, Lafayette, LA 70508             P.O. BOX 14748, Baton Rouge, LA 70898-4748                                          SCHEDULE CONTINUED ON BACK
          Phone: (337) 262-5990, ext. 16 •                     Phone: (225) 925-1748
                         ACADIANA DISTRICT SENIOR GAMES                                                                       ACADIANA DISTRICT SENIOR GAMES ENTRy fORM
                               2011 TEAM ROSTER                                                                                                               - RETURN THIS FORM -
                                                                                                                                  Return 1) entry form, 2) waiver, 3) entry fees, and 4) birthdate verification to:
    Only one entry form per team should be completed and submitted with the entry form by the team coach,                                Acadiana District Senior Games, ATTN: Jody Thibodeaux
    captain, or other designated individual. All communication will be directed to the captain. It will be the                                    160 Industrial Pkwy., Lafayette, LA 70508
    captains responsibility to turn in the roster and contact players regarding changes.                                                   Make checks payable to Lafayette Council on Aging, Inc.

T   Dance Team competition has two age categories: 50 - 59; 60+                                                                       fILL IN EACH BLANK WITH ONE LETTER OR NUMBER.
                                                                                                                                     PLEASE PRESS HARD WHEN FILLING IN BLANKS. USE BLACK BALLPOINT PEN.
                                                                                                                 L CHECK If NEW ADDRESS

E                                                                                                                                                                                                                                                 N
       you Must Include Individual Team Members’ Entry forms and I.D. Attached to This Entry form.
                                                                                                                 LAST NAME                                                   FIRST NAME                                     MI       SEX

                                                                                                                 MONTH      DAY       YEAR (BIRTHDATE)      US VETERAN?      NAME YOU MOST OFTEN USE
    SPORT:     l DANCE TEAM (mixed - max. roster 15) - Age 50 - 59                                                                                          Y     N
               l DANCE TEAM (mixed - max. roster 15) - Age 60+                                                   ADDRESS
               l BEAN BAG BASEBALL 50+
A                                                                                                                CITY

                                                                                                                                                                                           STATE     ZIP

                                                                                                                                                                                                  TELEPHONE: HOME
                                                                                                                                                                                                                            PLUS FOUR

M                                                                                                                                                                                                                                                 R
                                                                                                                 TELEPHONE: OTHER                             E-MAIL ADDRESS
    Team Name: _____________________________________________________________________________                              –
                                                                                                                 SHIRT SIZE: (Circle One) Small Medium Large X Large XX Large XXX Large All T-Shirts $5.00 (Remember to add $5 for shirts)
    Team Captain: ____________________________________________________________________________
                                                                                                                        CHECK EACH SPORT AND EVENT IN WHICH yOU WISH TO PARTICIPATE

                                            TEAM MEMBERS
                                                                                                                                     quALIFYING EvENTS for the 2010 STATE GAMES are marked with an asterisk (*).
                                                                                                                          IMPORTANT: AVOID CONfLICTS By CHECKING GAMES SCHEDULE fOR START TIMES!                                                  Y
                                                                                                                     BADMINTON            L	 BENCH PRESS           L	 *GOLf, medal              PICKLE-BALL                  TRACK & fIELD
                                                                                                                 L	 Singles                                                                  L	 Doubles                 NOTE: A maximum

E   1. ______________________________________________

    2. ______________________________________________
                                                           11. _____________________________________________

                                                           12. _____________________________________________
                                                                                                                 L	 Doubles
                                                                                                                    partner: _______
                                                                                                                                          L	 BILLIARDS

                                                                                                                                          L	 *BOWLING singles
                                                                                                                                                                   L	 MINIATURE GOLf

                                                                                                                                                                                                partner: _______
                                                                                                                                                                                             L	 Mixed Doubles
                                                                                                                                                                                                partner: _______
                                                                                                                                                                                                                        of 3 running events,
                                                                                                                                                                                                                        1 walking event and
                                                                                                                                                                                                                        3 field events.
                                                                                                                                                                                                                        L	 50 M Dash
                                                                                                                                                                   *Choose only 1 of the
                                                                                                                 L	 Mixed Doubles                                                                                       L	 100 M Dash
                                                                                                                                                                     horseshoe events              SWIMMING
                                                                                                                                                                   L	 Recreational
    3. ______________________________________________      13. _____________________________________________                                 CARD GAMES
N                                                                                                                                         L	 Bourré                                                                     L	 200 M Run
                                                                                                                                                                                                  50 M Free
                                                                                                                    partner: _______                               L	 *Advanced              L	
                                                                                                                                          L	 Texas Hold’em                                                              L	 400 M Run
                                                                                                                                                                                                  100 M Free
    4. ______________________________________________      14. _____________________________________________                 _______
                                                                                                                                                                                                                        L	 800 M Run
                                                                                                                                                                                                  50 M Back
                                                                             DANCE TEAM                                                                             MARKSMANSHIP             L	
                                                                                                                 L	 BAIT CASTING          L	 CROQUET                                                                    L	 1500 M Run
                                                                                                                                                                                                  100 M Back
    5. ______________________________________________      15. _____________________________________________                                                       L	 Pistol .22             L	   50 M Breast
                                                                                                                                                                   L	 Rifle .22              L	                         L	 5K Run

T                                                                                                                                                                                                                                                 O
                                                                                                                                                                                                  100 M Breast
    6. ______________________________________________                                                                 BASKETBALL                                                             L	   100 M Medley          L	 800 M Recreational
                                                                                                                 L	 Freethrow                                        *SHUffLEBOARD                                           Walk
    7. ______________________________________________                                                                                                              *Choose only 1 of the        *TABLE TENNIS           L	 1500 M Race Walk
                                                                                                                                                                    shuffleboard events      L	 Singles                 L	 *Discus
                                                                                                                                                                   L	 *Advanced                                         L	 High Jump
                                                                                                                                                                   L	 Recreational
    8. ______________________________________________

R                                                                                                                                                                                                                                                 R
                                                                                                                                                                                             TENNIS (1 can balls)
                                                                                                                                                                                             L	 Doubles                 L	 *Javelin
    9. ______________________________________________                                                            L	 *DANCE TEAM – Age 50 - 59                                                   partner: _______        L	 Long Jump
                                                                                                                    Team name and captain: __________________________                                                   L	 Triple Jump
               BEAN BAG BASEBALL                                                                                                                                                             L	 Mixed Doubles
    10. _____________________________________________                                                                   ______________________________________________                                                  L	 *Shot Put
                                                                                                                                                                                                                        L	 *Hammer Throw
                                                                                                                                                                                                partner: _______

Y                                                                                                                L	 *DANCE TEAM – Age 60 +
                                                                                                                    Team name and captain: __________________________
                                                                                                                                                                                                  Football Accuracy
                                                                                                                                                                                                  Frisbee Accuracy
                                                                                                                                                                                                  Softball Accuracy
                                                                                                                                                                                                                        L	 Pole vault
                                                                                                                                                                                                                        – To enter the Hammer
                                                                                                                                                                                                                        Throw, you MuST enter
                                                                                                                                                                                                                        one of the other weight
                                                                                                                 L	 BEAN BAG BASEBALL – Age 50 +                                             L	   Softball Distance     throws (discus, shot or
                                                                                                                    Team name and captain: __________________________                        L	 WASHER PITCH            javelin)

                                                                                                                             NOTE: NO REGISTRATIONS OR ADD-ONS ARE AllOwED AT EVENT SITES!!!
                            ACADIANA DISTRICT SENIOR GAMES                                                                                                           ACADIANA DISTRICT SENIOR GAMES
                                         MEDICAL INfORMATION                                                                                                              INfORMATION fOR ALL ENTRANTS

I   Louisiana Senior Olympic Games STRONGLY URGES that participants CONSULT THEIR PHYSICIANS in regard
    to practice, preparation, and competition in the Senior Olympic Games Program.
                                                                                                                                      INSTRUCTIONS fOR ALL PARTICIPANTS:
                                                                                                                                         1. Print or type all information requested on an entry form.                                                                    I
                                                                                                                                         2. Waiver must be signed and dated at the bottom of entry form.
                                                                                                                                         3. Inlcude payment of all fees, additional guest for meals, tee shirts, Golf, Bowling, and Miniature Golf.

    ACADIANA AMBULANCE MEMBER? YES _____ NO _____ MEMBERSHIP # ___________________________________
                                                                                                                                         4. Include proof of age if you are a first time participant.
    EMERGENCY CONTACT - FAMILY _________________________________________ Phone _______________________                                   5. Shirt Size.

F                                                                                                                                     AGE CATEGORIES (determined by age as of December 31, 2010):

    PARTICIPANT WAIVER AND MODEL RELEASE                                                      SIGN BELOW
                                                                                                                                            50-54       55-59         60-64        65-69          70-74

    In consideration of being allowed to participate in any way in the Louisiana Senior Olympic Games program, related events               75-79       80-84         85-89        90+
    and activities, the undersigned acknowledges, appreciates, and agrees that:
                                                                                                                                               (Ages 40-49 eligible to participate in Track & Field, Golf, and Swimming)

    1. The risk of injury from the activities involved in these programs is significant, including the potential for permanent
       disability and death, and while particular rules, equipment, and personal discipline may reduce this risk, the risk of
       serious injury to me does exist; and,

    2. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both know and unknown, EVEN IF ARISING FROM THE NEGLIGENCE                                                                                  ENTRy fEES
       OF THE RELEASEES or others, and assume full responsibility for my participation; and,

&   3. I willingly agree to comply with the stated and customary terms and conditions for participation. If I observe any unusual
       significant concern in my readiness for participation and/or in the program itself, I will remove myself from participation
                                                                                                                                      ENTRY FEES must be sent with this form - checks made payable to: lafayette Council on Aging.
                                                                                                                                          •    ENTRY FEE paid by March 18 (for first three Sports)                                          $25.00         $    25.00
       and bring such to the attention of the nearest official immediately; and,
                                                                                                                                          •    ADDITIONAL FEE for each number of Sports over three:                            ______   X   $ 3.00 =       $ _____ .00
    4. I, for myself and on behalf of my/our heirs, assigns, personal representatives and next of kin, HEREBY RELEASE the Louisiana
       Senior Olympic Games Inc., its officers, officials, agents and/or employees, other participants, sponsoring agencies,
       sponsors, advertisers, and, if applicable, owners and lessors of the premises used to conduct the event (“Releasees”),
                                                                                                                                               ADDITIONAL FEE for BOWLING
                                                                                                                                               ADDITIONAL FEE for GOLF
                                                                                                                                                                                                                                                           $ _____ .00
                                                                                                                                                                                                                                                           $ _____ .00
       WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, or loss or damage to person or property incident to my

                                                                                                                                          •    ADDITIONAL FEE for MINIATURE GOLF                                                            $ 4.50         $ _____ .00
       involvement or participation these programs, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR
       OTHERWISE, to the fullest extent permitted by law.                                                                                 •    ADDITIONAL FEE for T-SHIRT                                                                   $ 5.00         $ _____ .00
                                                                                                                                          •    ADDITIONAL GUEST(S) for CELEBRATION OF ATHLETES                                 ______   X   $ 5.00 =       $ _____ .00
    5. I, for myself and on behalf of my/our heirs, assigns, personal representatives and next of kin, HEREBY INDEMNIFY AND

A      HOLD HARMLESS all the above Releasees from any and all liabilities incident to my involvement or participation in these
       programs, EVEN IF ARISING FROM THEIR NEGLIGENCE, to the fullest extent permitted by law.                                           To help support Acadiana District Senior Olympic Games, I have enclosed a donation of: $ _____ .00
                                                                                                                                              (All donations are tax deductible.)                                                                                        F
    I, the undersigned participant, grant to the Louisiana Senior Olympic Games, Inc. the right to use any picutres taken of me

    during the Louisiana Senior Olympic Games without my remuneration and in any medium the photographer/staff sees fit for                                                                   TOTAL AMOUNT ENCLOSED              $ _____ .00
    art, advertisement, exhibition, editorial, or any purpose whatsoever.

                                                                                                                                      PlEASE help us determine the number of meals to prepare by providing the information below.
                                                                                                                                      I will attend the Celebration of Athletes l Yes l No                PLUS ________ additional guests at $5.00 each.                 E
V   WITHOUT ANy INDUCEMENT.                                                                                                           Raffle tickets will be sold at the door for prizes. $1 for one ticket or $5 for six tickets.

    SIGNATURE ______________________________________ PRINTED ____________________________ DATE ____________                           I have checked the sport/event entries on this form and verify that they are correct. I have also signed the liability
E   EMERGENCY CONTACT: NAME ______________________________________________ PHONE _______________________
                                                                                                                                      waiver. I understand there are NO SUBSTITUTIONS or REfUNDS. All fees are enclosed.

R                        H H PACKET PICK-UP fOR 2011 H H
                                                                                                                                      Signature is required ________________________________________________ Date:________________________
                     Each Acadiana Registered Participant will pick up their Packet
                               at the site of their FIRST EVENT (SPORT).
                                                                                                                                       H THIS fORM MUST BE SIGNED AND RETURNED WITH PARTICIPANT APPLICATION fORM H

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