Jamaica Masters Athletics Association

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NAME --------------------------------- christian middle surname ADDRESS - ---------------------------------------------------- ---------------------------------------------------- ---------------------------------------------------- ---------------------------------------------------- DATE OF BIRTH- -----/---------/--------- day month year TELEPHONE - HOME------------------- CELL OCCUPATION - ------------------------------ MEDICAL HISTORY Are you being treated for any allergy or illness ? If yes please state.---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Doctors name - -------------------------------- Address ----------------------------------- Telephone ------------------------------------ EVENT Please place an X to indicate your event DISTANCE - 5K _ 8K _ 10K _ MIDDLE DISTANCE- 800m _ 1500m _ 5000m_ SPRINTS - 100m _ 200m _ 400m _ HURDLES - 100M Hurdles _ 400m Hurdles _ JUMPS- Long Jump _Triple jump _ High Jump _ FIELD - Discus _ Shot Put _ Javelin _ Hammer COMBINED EVENTS- Pentathlon _ Decathlon _ Heptathlon _ Signature of applicant -------------------Date------------- Approved by --------------------------- Date-----------------