Men's Region III Gymnastics Injury Petition Form
(This form may replace the national form for use to the Region III Championships)
Directions: (Fill in the blanks and then print or just print a blank form)
Fill out the petition form and give it to your State Chairman.  The name of the gymnast and his entry check should be forwarded to the meet director with the team entries stating "petition pending."  Petition forms should be accompanied by physicians statement and past meet results. Gymnasts should show from previous scores the ability to easily beat the Region qualifying score (over 2.0 points).
Gymnast's Information
Gymnast's Name:    Birthdate: Age Group:
USAG #: Level: School Grade: 3 4 5 6 7 8 9 10 11 12
City: State: Zip:
Home Phone:
Type of Injury: (Attach physician's statement)
Meet Information (Attach copies of actual meet results)
Name of Meet: Date: A/A Score:
Name of Meet: Date: A/A Score:
Coach & Club Information
Coaches Name: 
Club Name: 
Club Address:
City: State: Zip:
Day Phone:   Evening Phone:
Contact Email:

To be approved by State Chairman

Petition has been     Accepted:        Rejected:     Date:
Signature: ______________________________