2007 Region V Injury Petition

Illinois Injury Petition Must be submitted online and the gymnast must be listed on your regional entry form. The Doctors Note & copy of scores must be Faxed or Next Day Mail. (If sending by next day mail make sure to mark it to be left without someone having to sign for it)  Deadline  -  In hand 3 Days after last qualifying Meet.
To: Regional Technical Committee Assistant, State Chair, IL JO Chair, & Level Chair

State Meet Petitioning To:

Gymnast Name:

USAG#   Birthdate:                   Leo Size:

Coach's Name:  Phone #:             Email:

Gym Name: Club#

Address:  City:

State:               Zip:             Gym Phone:

1. One Sanctioned Meet:

Meet:               Date: 
Vault: Bars:             Beam:             Floor:AA:            

2.Must Fax or Overnight Mail the Physician's written verification of Illness or injury and a date of release for return to activity. To:  State Chair, IL JO Chair, Level Chair
Comments:

I hereby acknowledge all rules and regulations handed down by USA Gymnastics and Region V. 
 I have read and understand all information pertaining to this petition.  This petition  form contains all the proper names, Birthdates, USAG numbers, and legal levels.
 
By Submitting my name on this form I understand that I ALSO MUST FAX OR OVERNIGHT MAIL THE DOCTOR'S NOTE TO ALL THE REQUIRED PEOPLE BY THE DEADLINE AND am Financially Responsible for all gymnast listed on this form.

Submitted By: Date: