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Vertical Adventures
2nd Annual
Fall Vault @ The Mount Laurel Fall Festival
September 16, 2017
Laurel Acres Park
1045 Church Street, Mount Laurel, NJ
*Rain Date, September 17
*After Your Competition, Enjoy The Festival
For Music, Food, Fun & Entertainment!
Mail Entry Form & Check Payable To:
Michael Pascuzzo
1 Sheffield Lane
Mt. Laurel, NJ 08054
Phone: (856) 231-0769/cell (609) 304-5393
MPScooze@aol.com
www.VerticalAdventures.org
Parental Consent/Participation Waiver:
I hereby grant permission for my child to participate in the Vertical Adventures Fall Vault, to
be held September 16/17, 2017 in Mount Laurel, NJ. I verify that my child has had a physical
exam in the past year and is able to participate in the activities related to the Vertical Adven-
tures Fall Vault. I agree to indemnify, hold harmless and defend Michael Pascuzzo, Vertical
Adventures, Nickolas Tyson, All Vertical Adventures Fall Vault Coaches & Staff, All Fall Vault
Sponsors and/or their agents or employees from any and all liability for injury to my child, as
well as any injury or damage caused by my child. Should medical treatment for my child be
necessary, I hereby authorize any physician, trainer or EMT selected by Fall Vault personnel to
order and conduct medical or surgical procedures necessary. I also understand that an addi-
tional Waiver & Release of Liability will be e-mailed to me upon registration. I understand that
my child is NOT permitted to participate in the Vertical Adventures Fall Vault unless & until
this additional Waiver & Release of Liability has been completed, Signed & returned to the
event organizers!
Parent/Guardian/Participant Signature:
___________________________________Date:_________
*Complete Participation Waiver E-mailed After Confirmation!
Athletic Bio / Stats / Credentials
Personal Best: _____Feet ____Inches
Titles Won (if any) ___________________
__________________________________
__________________________________
__________________________________
__________________________________
Best PV Memory/Moment As An Athlete:
__________________________________
__________________________________
__________________________________
For The BEST Track & Field Summer Camps,
Clinics, Meets & Events In The World, Visit
www.VerticalAdventures.org
*Private Pole Vault & High Jump Coaching, Too!
This Pole Vault Venue Is “On Top” Of
Laurel Acres Park’s 70 Foot High Sledding Hill,
Offering Vaulters A Panoramic View Of The
Mount Laurel Fall Festival!
Who Will Be Crowned King & Queen
Of The Hill This Year?
Fall Vault 2016 Action
Atop The Hill!
Vertical Adventures Fall Vault 2017
Saturday, September 16
Two Competitions, Ages 13 & Up
ALL Skill Levels Welcome!
10am (PR’s Under 12’0”)
*Registration Limited, Register ASAP!
Followed By
*ATTN: Afternoon Competition On Saturday Is A Rolling Start!
Competitors MUST Arrive At Least 1 Hour Prior To Their Event!
1pm approx. (PR’s of 12’0” & Up)
*Registration Limited, Register ASAP! *Rain Date Is Sunday, September 17. Same Start Times Apply!
This Pole Vault Venue Is “On Top” Of Laurel Acres Park’s 70 Foot High
Sledding Hill, Offering Vaulters A Panoramic View Of The Fall Festival!
Who Will Be Crowned King & Queen Of The Hill This Year?
Vertical Adventures Fall Vault Entry Form
Name___________________________________
Age________ Gender (circle) Male Female
School/Club_____________________________
Address_________________________________
Town_____________ State____ Zip Code_____
*Cell Phone # (_____)_____________________
*Mandatory: Allows Us To Contact You If Needed!
*E-Mail Address:
________________________________________
*Mandatory, Please Print Legibly! This Is Our
Primary Method Of Contact With ALL Participants!
Personal Best _______Feet _______Inches
*Current USATF# ________________________
*Mandatory For ALL Participants!
Competition Entered (circle)
PR’s Under 12’0”
For Ages 13 & Up, Including
Middle School Girls & Boys, HS Girls & Boys,
College/Open Women & Men
& Masters Women & Men
PR’s 12’0” & Up
For HS Girls & Boys, College/Open Women & Men,
& Masters Women & Men
Registration Fee
____ $45 (If Received By August 31)
____ $55 (If Received By September 15)
____ $65 (Day Of Event / *MUST CALL 1st)
*Call Mike Pascuzzo @ (609) 304-5393
-Complete Other Side To Register
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