Quad City Senior Olympics 2017

Registration


ALL PARTICIPANTS must be 50 years of age by May 31, 2017. Registration deadline for all events is May 20, 2017.

$25 Entry Fee plus $5.00 added fee for all Pickleball entries.

 


First Name
Last Name

Address

City
State
Zip
Phone
Alt Phone
Email
Birthday (MM-DD-YYYY)
Age on date of competition
Sex

Emergency Info  
Emergency Contact Name
Emergency Contact Relationship
Emergency Contact Phone
Will anyone accompany you to the games
 

Attending Complimentary Opening Ceremonies Meal
Additional Guest Meals ($10 per guest meal)
Attending Complimentary Closing Ceremonies Meal
Additional Guest Meals ($10 per guest meal)
I am competing in Pickleball ($5 registration fee)  
I would like a T-Shirt (Shirts are $10)  
T-Shirt Size   S-M-L-XL-XXL-XXXL
 
CHECK EVENTS ENTERED – NOTE:  There will be no accommodation for schedule conflicts, except bowling. Quad Cities Senior Olympics, Inc strongly recommends that each participant consult his or her own physician with regard to competing in these events.
 
Individual Athletic Events
 
Archery
Compound Bow Hunter
Compound Bow Release
Compound Bow Fingers
Compound Bow Unaided
Recurve/Freestyle
Recurve/Freestyle Limited
Recurve/Freestyle Traditional
 
Badminton
Badminton - Singles
Badminton - Doubles
 
Basketball
Basketball Free Throw
Basketball Around the World
Basketball 3-point
 
Sports
Bench Press
Billiards
Bowling
Bulls Eye Pistol
Cycling 10K
10K Time Trials at Preemption, IL - 1/4 mile west of 67 on 170th Ave
Cycling 16 Miles
16 Mile Road Race at Adventure Quest, 3501 207th St. N, Port Byron, IL on GPS
Disc Golf
Golf
Horseshoes
Shuffle Board - Singles
Shuffle Board - Doubles
Shuffle Board - Mixed Doubles
Skill Levels required: 2.5-3.0/Adv Int:3.5-4.0/Adv: 4.5-5.0
Pickleball Men's Singles
Pickleball Women's Singles
Pickleball Men's Doubles

Need a Partner
Skill Level
Pickleball Women's Doubles

Need a Partner
Skill Level
Pickleball Mixed Doubles

Need a Partner
Table Tennis Singles
Table Tennis Doubles
Tennis Singles
Tennis Doubles
Tennis Mixed Doubles
 
Swimming
50 Back
50 Breast
50 Fly
50 Free
100 Back
100 Breast
100 Fly
100 Free
100 IM
200 Free
500 Free
   
Track and Field
5K Run/Walk
Football Throw - Distance
Football Throw - Accuracy
Softball Throw - Distance
Softball Throw - Accuracy
Disc Golf - Distance
Disc Golf - Accuracy
Soccer Accuracy Kicking
50M
100M
200M
400M
800M
1500M
3,000M
4 x 100 Relay
Discus
Javelin
Pole Vault
Shot Put
Weight Throw
High Jump
Standing Long Jump
Running Long Jump
Triple Jump
   
Sports
Air Pistol Silhouette
   
Thinking Events
Spelling Bee
Trivia
 
Performing Arts
Drama - Solo
Title:
Drama - Group
Title:
Vocal - Solo
Vocal - Group
Dance - Solo
Type:
Dance - Group
Type:
Instrumental - Solo
Instrument:
Instrumental - Group
Names of other performers in small groups:
   
Literary Arts  
Fiction
Non-Fiction
Poetry-Rhyming
Poetry-Free Verse
   
Ballroom Dance
East Coast Swing
Partner:
Age:
Waltz
Partner:
Age:
   
Arts & Crafts - 3D  
Ceramics
Metal
Mixed Media
Polymers
Pottery
Sculpture
Wood Carving
Beading/Jewelry
Other
Arts & Crafts - Drawing  
Charcoal
Pen & Ink
Pencil/Colored Pencil
Other
Arts & Crafts - Fiber  
Counted Cross Stitch
Crochet
Cross Stitch
Dolls
Embroidery
Knitting
Needle Work
Quilting
Other
Arts & Crafts - Painting  
Acrylic
Mixed Media
Oil
Pastel
Watercolor
Other
Arts & Crafts - Photography  
Black & White
Color
Other
 

 

Entry Fee $25
On site facility fees - bowling is $6.75, Billiards is $3.00, Golf is $10.00

After winning 3 medals, a donation of $3 per medal is requested.

Athletes may make a donation to the Quad Cities Senior Olympics, Inc. - Not for Profit 501 c3 organization.
 

WAIVER STATEMENT
In consideration for being allowed to participate in any way in the Quad Cities Senior Olympics athletic/sports program, related events and activities, I __________________________, the undersigned acknowledge and agree that:

  1. The risk of injury from the activities involved in this program is significant, including the potential for permanent paralysis and death, and while particular rules, equipment, and personal discipline may reduce this risk, the risk of serious injury does exist and,
  2. I knowingly and freely assume all such risks, both known and unknown, even if arising from the negligence of others, and assume full responsibility for my participation and,
  3. I willingly agree to comply with the stated and customary terms and conditions for participation, If however, I observe any unusual significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the nearest official immediately and,
  4. I, on behalf of myself and my heirs, assignees, personal representatives, and next of kin, hereby release and hold harmless Quad Cities Senior Olympics, Inc., their officers, agents, and/or employees, other participants, sponsoring agencies, sponsors, and advertisers, and if applicable, owners, and lessees of premises used to conduct the event, with respect to any and all injury, disability, death, or loss or damage to person or property, whether arising from the negligence of the releases or otherwise.

I have read this release of liability and assumption of risk agreement, fully understand its terms, understand that I have given up substantial rights by signing it, and sign it freely and voluntarily without any inducement.

I agree to the waiver statement
Donate $
Registration Fee $25
T-Shirt Fee $0
Guest Meal Fee $0
Pickleball Fee $0
   
Total $25.00
When pressing the "submit" button, the registration information will be emailed to the QCSO office. You can use the Paypal button below or mail the amount shown above to Quad Cities Senior Olympics, (QCSO), 1800 3rd Ave, Suite 304, Rock Island, IL, 61201. The check or money order must be received by the QCSO Office by Friday, May 20, 2016. DO NOT SEND CASH!