OFFICIALS APPLICATION FORM

2009 USA MASTERS INDOOR TRACK & FIELD CHAMPIONSHIPS

Prince George’s Sports & Learning Complex, Landover MD

March 20-22, 2009

Conducted by Potomac Valley Track Club • www.pvtc.org • 703-481-3530 • e-mail

Meet Officials coordinator John Haubert (703-960-2914 • )

Officials chair Dr. William Price

Name: ______USATF Association ______

Address: ______

(Street) (City) (State) (Zip)

Telephone: ( )______E-mail address: ______

USATF Officials Certification Number ______2009 USATF Membership # ______

Level: ___ Master ___ National ___ Association Years @ Current Level: ______

Male ___ Female ___ Were you an Official at the 2008 Masters meet in Boston? ____ Yes ___ No

Circle: Shirt size S / M / L / X Which days can you work? March 20 / March 21 / March 22 / All

Do you need housing? Y / N If yes, do you have a roommate preference? ______

Select the five events in which are best qualified. Use 1 as your top choice, 5 as your last choice

____ Starter ____ Umpire ____ Clerk ____ Weights & Measures

____ Marshall ____ Timer ____ Shot Put ____ Pentathlon

____ Long Jump ____ Triple Jump ____ Track events ____ Weight & Superweight

____ High Jump ____ Pole Vault ____ Race Walk ____ Other

Athletes in the meet may also serve as officials.

Officiating History

Please list major meets you have worked in the last 3 years, including USA championships and international competitions. List the name of each meet, the year you officiated, the event, and the position you worked in the meet. Add another page if necessary

Year / Meet Name / Event / Position

Participation agreement

• I recognize that certain inherent risks are involved in my participation in track and field competitions as an official, and I fully accept those risks. In consideration of application in being accepted for this event, I intending to be legally bound hereby for myself, my heirs, executors and administrators, waive, release and forever discharge all rights and claims for damages which I may have or which accrue to against Potomac Valley Track Club, USA Track & Field, the sponsors, Potomac Valley Association of USA Track & Field, Maryland-National Capitol Parks & Planning Commission, and their sponsors, officers, agents, representatives successors and /or assigns, for any and all damages which may be sustained and suffered by me in connection with my participation in the meet, travel to and from the meet.

• I understand that a Track & Field Official who participates in the meet is responsible for any and all costs incurred for travel, transportation, meals, and uniforms beyond those provided by the hosts.

• I agree to abide by all regulations for participation at the meet and hereby certify that all personal information submitted by me for consideration of my application is true to the best of my knowledge.

Signature of Applicant: ______Date: ______

Submit this form to: PVTC • 611 South Ivy Street • Arlington VA 22204-2429