]
(Registration) Code [
(office use only, do not write here)
XIII European Masters Championships
Yalta-Kiev 2011
)
(Surname)
Yalta 2011 Kiev
(Gender)(ACCREDITATION) FORM
/
/
/ (Your age on 31/12/2011)
th)
--------------------------------------------------------------------------------- INDIVIDUAL REGISTRATION
------------------------------( DD)
)
ress)
INDIVIDUAL REGISTRATION (ACCREDITATION) FORM
(MM)
(YYYY)
(MALE)
Accreditation
(Registration) Code [_______________________]
(Country code)
Accreditation (Registration) Code [
]
(office use only, do not write here)
(office use only, do not write here)
(City)
(Given Name) _______________________________________
(Given
__ Name)
(Country)
e)
(FEMALE)
(Family name) _______________________________________
(Surname)
(E-mail)
of birth) /_____/_____/________/
(Your age on 31/12/2011)
(Date of birth)
(Gender) _____________
/(Date /
/ (Your age on 31/12/2011)
---------------------------------------------------------------------------------------------------------------
hone number) + /
/
( DD)
(Nationality)
, if you are club member)
(Street address)
Yalta 2011 Kiev
(MM)
(YYYY)
(Gender)
( DD)
(MM) fax
(YYYY)
(Contact
number)
(MALE)
+ /
/
(MALE)
(FEMALE)
(FEMALE)
(Country code)
(City of your club)
(City) (Country code)
(Nationality) _______________________________
(Street address) __________________________
(City) ____________________
(Postal code)
__ (Country)
(E-mail)
Yalta-Kiev
2011 discipline
compete
in the following
(Postal code) _____________ (Country) _________________________________
phone number)
/ _____________________________________________________________
/ not going to compete!
(Contactdiscipline
(Contact fax number) + /
/
o notUkraine
tick sports
if +you
are
(E-mail)
5-10 September
(Contact phone number) + ____/___/____
member) relay
(Club name, if you are club
Swimming
mming Office
individual
510, Kiev,
42 Esplanadna Str.,
(City of your club)
Diving
01601, Ukraine
(Club name) __________________________________________________________
E-mail: [email protected]
(City of your club) ______________________________________________________
hronised
swimming
Fax: +38 (044) 2894211
/
(Contact fax number) + ____/___/____
Open water
swimming
I intent to compete in the following discipline
www.yaltamasters2011.org
I intent to compete in the following discipline
Please, do not tick sports discipline if you are not going to compete!
Swimming individual
Swimming relay
Diving
Swimming individual
relay
Synchronised swimming Swimming
Open
water swimmingDiving
Synchronised swimming
Open water
swimming
(date) _____/______/______ (Your signature) ________________
/
(Your signature)
's official name)
(Federation's official name) ___________ (Federation's official signature) _________
Please submit this form no later than June
22, 2011
_ (Federation's official signature)
Mail to: Yalta/Kiev 2011 OC,
mit this form no later than June4222,
2011 byStr.,
Fax No
(044)
28901601,
4211 or,Ukraine
Esplanadna
off.+38
510,
Kiev,
42 Esplanadna
[email protected](date)
Mail to:/Yalta/2011 OC, (Your
signature) Str., off. 510, Kiev, 01601, Ukraine
(Federation's official name)
_ (Federation's official signature)
Please submit this form no later than June 22, 2011 by Fax No +38 (044) 289 4211 or,
E-mail: [email protected] Mail to: Yalta 2011 OC, 42 Esplanadna Str., off. 510, Kiev, 01601, Ukraine
29
NDIVIDUAL REGISTRATION (ACCREDITATION) FORM
XIII ]European Masters Championships
tion (Registration) Code [
(office use only, do not write here)
Yalta-Kiev 2011
Yalta 2011 Kiev
me)
SWIMMING ENTRY FORM
(Surname)
* Any competitor may enter a maximum of five (5) individual events, no more than two (2)
events per day.
* Print in your real entry time in appropriated box, beside event you wish to compete. Time
birth)
(Gender)
/
/
/ (Your
age onwithin
31/12/2011)
must
be achieved
last 12------------------------------month at Masters
Event.
--------------------------------------------------------------------------------*
All
entries
must
be
authorized
by
the
competitor's
national
federation.
( DD)
(MM)
(YYYY)
(MALE)
(FEMALE)
(Given Name) ______________________ (Family name) ________________________
(Country code)
(Club Name) ______________________ (Age on 31 December 2011) _____________
lity)
address)
(City)
(City/Country) ___________________________________________________________
competitors who enter 400 m., 800 m. Freestyle must
__ (Country)Please note! Reconfirmation of the
(E-mail)
code)
be done untill 18:00 a day prior the event, Open Water Swimming must be done until
12:00 a day prior the event. Otherwise no participation is possible.
+ / /
t phone number)
Yalta 2011 Kiev
(Contact fax number) + /
/
EVENT & ENTRY TIMES
MEN Entry Times Event №
Yalta-Kiev
2011
me, if you
are club member)
Even № WOMEN Entry Times
EVENT
(City of your club)
DAY 1 - Monday, 5 September, 2011 – 08:00
01
03
Ukraine
5-10 September
42 Esplanadna Str.,
to compete
in the following discipline
Office 510, Kiev,
06
08
10
200 m. Ind. Medley
800 m. Freestyle
DAY 2 - Tuesday, 6 September, 2011 – 08:00
200 m. Freestyle
50 m. Breaststroke
100 m. Butterfly
DAY 3 - Wednesday,7 September,2011 – 08:00
200 m. Butterfly
50 m. Backstroke
100 m. Breaststroke
400 m. Freestyle Women
DAY 4 - Thursday, 8 September, 2011 – 08:00
200 m. Backstroke
50 m. Butterfly
100 Freestyle
400 m. Freestyle Men
DAY 5 - Friday, 9 September, 2011 – 08:00
200 m. Breaststroke
50 m. Freestyle
100 m. Backstroke
DAY 6 Saturday,10 September, 2011 – 10:00
3 km. Open Water
01601,
Ukraine
, do not
tick
sports discipline if you are
not going to compete!
13
Fax: +38 (044) 2894211
E-mail: [email protected]
www.yaltamasters2011.org
15
17
----
Swimming relay
wimming individual
-----
nchronised swimming
22
Open water
24
swimming
26
28
29
31
33
/
/
Diving
14
16
18
20
21
23
25
----
------
30
32
34
(Federation's official name) ___________ (Federation's official signature) _________
Please submit this form no later than June
22, 2011
_ (Federation's official signature)
Mail to: Yalta/Kiev 2011 OC,
ubmit this form no later than June
22, 2011 by Fax No +38 (044) 289 4211 or,
42 Esplanadna Str., off. 510, Kiev, 01601, Ukraine
[email protected] Mail to: Yalta 2011 OC, 42 Esplanadna Str., off. 510, Kiev, 01601, Ukraine
30
05
07
09
(date) _____/______/______ (Your signature) ________________
(Your signature)
tion's official name)
02
04
DIVIDUAL REGISTRATION
XIII(ACCREDITATION)
European MastersFORM
Championships
]
(Registration) Code [
(office use only, do not write here)
Yalta-Kiev 2011
Yalta 2011 Kiev
SWIMMING RELAY TEAM ENTRY FORM
* Competitor may only swim for club shown on the individual entry form and have
completed individual entry form.
(Surname)
* Competitor may only compete in one age group of the same event.
* Please print in estimated time for event you wish to enter.
* All entries must be authorized by the competitor's national federation.
)
(Gender)
/
/
/ (Your age on 31/12/2011)
th)
--------------------------------------------------------------------------------------------------------------( DD)
(MM)
(YYYY)
(Club Name) _____________________
(Club Code) |_____|_____|_____|
(MALE)
(FEMALE)
(Club Address) _________________________________________________________
)
(Country code)
(Postal Code) _________________________ (City) ___________________________
ress)
(City)
(Country) ____________________________
__ (Country)
e)
Yalta 2011 Kiev
hone number) + /
/
Yalta-Kiev 2011
Ukraine
, if you are
member)
club
5-10
September
42 Esplanadna Str.,
(Club E-mail) _____________________
(Club Phone) +_____________________ (Club Fax) +___________________________
(E-mail)
(Age group
of relay team)
Tick only one by(Contact
V
(100-119)
(120-159) (160-199)
+ / (200-239)
fax number)
/(240-279) (280-319) (320-359) (360+)
Swimming Relay Team Competitors Names:
(City of
1.
your2. club)
3. 4.
Office 510, Kiev,
01601, Ukraine
(044)
2894211 discipline
competeFax:in+38
the
following
Please note!
E-mail: [email protected]
Reconfirmation of the competitor’s names must be done until 18:00 a day prior the event.
www.yaltamasters2011.org
o not tick
sports discipline ifOtherwise
you are
goingisto
compete!
no not
participation
possible.
mming individual
hronised swimming
/
EVENT
Swimming
relay
Diving
ENTRY TIME
Event 11, 4 X 50 Freestyle WOMEN
Open water
Event 36, 4 X 50 Medley WOMEN
swimming
Event 12, 4 X 50 Freestyle MEN
Event 35, 4 X 50 Medley MEN
Event 19, 4 X 50 Medley MIXED
Event 27, 4 X 50 Freestyle MIXED
/
(Your signature)
's official name)
(date) _____/______/______ (Your signature) ________________
(Federation's official name) ___________ (Federation's official signature) _________
Please submit
this form no later
than June
22,
_ (Federation's
official
signature)
2011
Mail to:
Yalta/Kiev
2011
mit this form no later than June 22,
2011
by Fax No
+38 OC,
(044) 289 4211 or,
42 Esplanadna Str., off. 510, Kiev, 01601, Ukraine
[email protected] Mail to: Yalta 2011 OC, 42 Esplanadna Str., off. 510, Kiev, 01601, Ukraine
31
(office use only, do not write here)
me)
(Surname)
XIII
European Masters Championships
Yalta-Kiev 2011
Yalta/
2011 Kiev
birth)
(Your age on 31/12/2011)
(Gender)
/
/
---------------------------------------------------------------------------------------------------------------
( DD)
(MM)
(YYYY)
(MALE)
lity)
DIVING ENTRY FORM
(Country code)
address)
code)
__
(FEMALE)
* All competitors must enter under the name of their club.
(City)
* No qualifying limits has been fixed.
* Please fill in your personal data and tick the box(es) beside event(s) you wish to
participate.
(Country) * All entries must be authorized by
(E-mail)
the competitor's national federation.
t phone number) + /
/
(Contact fax number) + /
(Participant's Given Name) (Participant's Family Name)
/
(Age on 31 December 2011)
(City of your club)
me, if you are club member)
(Club Name)
(Age Group*)
Yalta 2011 Kiev
to compete in the following discipline
(City)
Yalta-Kiev 2011
Ukraine
e, do not tick sports discipline if you are not going to compete!
*There are following age groups:
25-29 years, 30-34 years, 35-39 years, 40-44 years, 45-49 years, 50-54 years,
55-59 years,
60-64 years,
65-69 years, 70-74 years,Diving
75-79 years, 80+ years.
Swimming
relay
5-10 September
wimming individual
42 Esplanadna Str.,
Office 510,swimming
Kiev,
nchronised
01601, Ukraine
Fax: +38 (044) 2894211
(Country)
Tick where
Openappropriate.
water
swimming
E-mail: [email protected]
WOMEN
www.yaltamasters2011.org
.
EVENT
1 m. SPRINGBOARD
MEN
3 m. SPRINGBOARD
PLATFORM
PLATF
ORM
/
/
(Your signature)(date)
tion's official name)
_____/______/______ (Your signature) ________________
(Federation's official name) ___________ (Federation's official signature) _________
_ (Federation's official signature)
Please submit this form no later than June
22, 2011
ubmit this form no later than June
2011 by2011
Fax NoOC,
+38 (044) 289 4211 or,
Mail22,
to: Yalta/Kiev
OC, 42 Esplanadna
Str.,510,
off. Kiev,
510, Kiev,
01601,
[email protected] Mail to: Yalta 2011
Ukraine
42 Esplanadna
Str., off.
01601,
Ukraine
32
FORM
DIVIDUAL REGISTRATION
REGISTRATION (ACCREDITATION)
(ACCREDITATION) FORM
DIVIDUAL
Registration) Code [
]
Registration) Code
[
]
(office use only, do not write here)
XIII
(office use only, do not write here)
European Masters Championships
Yalta-Kiev 2011
Yalta 2011 Kiev
(Surname)
(Surname)
SYNCHRONISED SWIMMING ENTRY FORM
h)
(Gender)
/
/
/ (Your age on 31/12/2011)
* All
competitors
must ------------------------------enter under the
name of their club.
h)--------------------------------------------------------------------------------(Your
(Gender)
/
/
/
age
on
31/12/2011)
( DD)
(MM)
(YYYY)
(MALE) (FEMALE)
-------------------------------------------------------------------------------------------------------------( DD)
(MM)
(YYYY)
ress)
ess)
)
* No qualifying limits has been fixed.
(MALE) beside
(FEMALE) event(s) you wish to
* Please fill in your personal data and tick the box(es)
participate.
(Country
code)
* All entries
(Country
code)must be authorized by the competitor's national federation.
(City)
(City)
__ (Country)
__ (Country)
one number) + /
one number) + /
/
/
(Participant's Given Name) (Participant's Family Name) (Age on 31 December 2011)
(E-mail)
(E-mail)
(Club Name)
(Contact fax number) + /
(Contact fax number) + /
Yalta 2011 Kiev
(City)
if you are club member)
f you are club member)
/
/
(City of your club)
(Country)
(City of your club)
Please tick on the boxes below appropriate event and age groups*
Yalta-Kiev 2011
Ukraine
Event
ompete 5-10
in theSeptember
following discipline
ompete in the following discipline
Age group
o not tick
sportsStr.,
discipline if you are not going
SOLO to compete!
42 Esplanadna
o not tick
Officesports
510, Kiev, discipline if you are not going to compete!
01601, Ukraine
ming individual
E-mail: [email protected]
ming individual
www.yaltamasters2011.org
ronised swimming
ronised swimming
Fax: +38 (044) 2894211
DUET
Swimming relay
TEAM
Swimming relay
Open water
Open
water COMBINATION
swimming
swimming
Diving
Diving
*There are following age groups: SOLO & DUET 25-29, 30-39, 40-49, 50-59,60-69,7079,80+ years; TEAM 25-34, 35-49, 50-64, 65+ years;
FREE COMBINATION 25+ years.
(date) _____/______/______ (Your signature) ________________
/
/
(Your signature)
(Your signature)
(Federation's official name) ___________ (Federation's official signature) _________
Please submit this form no later than June
22, 2011
_ (Federation's
s official name)
Mail to: Yalta/Kiev
2011 official
OC, signature)
official name)
_
official
(Federation's
signature)
42 Esplanadna Str., off. 510, Kiev,
01601, Ukraine
it this form no later than June 22,
2011 by Fax No +38 (044) 289 4211
or,
t
form
no
than
June
2011
by
Fax
No
+38
(044)
289
4211
or,
this
later
22,
[email protected] Mail to: Yalta 2011 OC, 42 Esplanadna Str., off. 510, Kiev, 01601, Ukraine
[email protected] Mail to: Yalta 2011 OC, 42 Esplanadna Str., off. 510, Kiev, 01601, Ukraine
33
XIII European Masters Championships
Yalta-Kiev 2011
Yalta 2011 Kiev
RELEASE FROM LIABILITY FORM
(Given Name) ____________________ (Family name) __________________________
(Date of birth) ______/______/_______/
( DD) (MM) (YYYY)
(Club name) ________________________________________
(City/Country)
Yalta 2011 Kiev
Yalta-Kiev 2011
Ukraine
5-10 September
42 Esplanadna Str.,
Office 510, Kiev,
01601, Ukraine
Fax: +38 (044) 2894211
E-mail: [email protected]
www.yaltamasters2011.org
__________________________________________________________
RELEASE FROM LIABILITY STATEMENT
I, the undersigned participant, intending be legally bound, hereby certify that I am physically
fit and have not been otherwise informed by medical practitioner. I acknowledge that I am
aware of the risks inherent in Masters Swimming, Diving, Open Water and Synchronised
Swimming (training and competition) including possible permanent disability or death, and
assume all risks.
I hereby waive all rights to claims for damages, arising out of my participation in XIII
European Masters Championships Events or any activities incidental there to, against
the Ligue Europenne de Natation (LEN) and OC Yalta/Kiev 2011 or any individuals
participating in Masters Swimming, Diving, Open Water Swimming and Synchronised
Swimming compatitions of the European Champioships 2011.
In addition I agree to abide by and be governed by the rules of the Ligue Europenne de
Natation (LEN).
I further declare that I have sufficient health insurance valid in Ukraine to cover any medical,
pharmaceutical, hospitalization and repatriation expenses.
That my occur in connection with my stay and participation at the 13th European Masters
Championships in Swimming, Diving, Open Water Swimming and Synchronised Swimming
Yalta/Kiev 2011. I understand and agree that the OC of Yalta/Kiev 2011, LEN or Ukrainian
authorities may request to submit evidence of such insurance coverage for participation on
the event for myself as well as for any friends and/or family members intending to join me
for the event.
Both XIII European Masters Championships participants and companions are responsible
for their own traveling and personal expenses.
(date) ______/ ______/________
Your signature) _____________________
Please submit this form no later than June
22, 2011
Mail to: Yalta/Kiev 2011 OC,
42 Esplanadna Str., off. 510, Kiev, 01601, Ukraine
34