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