5TH UTTAR PRADESH STATE OPEN ROLLER SPORTS CHAMPIONSHIP

AT JSR 25-26 MAY 2024 GHAZIABAD

INDIVIDUAL ENTRY FORM
RSFI ANNUAL REGISTRATION NO. …………………………… (Mandatory) PHOTO

NAME (CAPITAL LETTERS) …………………………………………….

FATHER’S NAME ……………………………………………..

MOTHER’S NAME ……………………………………………

RESIDENTIAL ADDRESS ………………………………………………………………

……………………………………………………………………………………………………….

MOBILE NO …………………..…… M/F ……….

DATE OF BIRTH ………/………/………

REPRESENTING D I S T R I CT …………………………………………………

COACH’S NAME………………………………………………………….

INDICATE THE YEAR YOU REGISTERED WITH RSFI FOR THE FIRST TIME ………………

Age group ………………………………………………

NOTE:- DATE OF BIRTH as on 31/12/2024

PLEASE CIRCLE THE EVENTS YOU ARE PARTICIPATING IN

Age- YEAR Quads Rink In Line Rink

Group R1 R2 R3 ROAD1 ROAD2 R4 R5 R6 ROA ROA Road5
D3 D4
5-7yrs* 2018-2019 2 LAP 4 lap 6 2 LAP 4 Lap 6LAP 100
LAP MTR
7-9yrs 2016- 2 LAP 500+D 1000 1 LAP 2 LAP 500+D 1000 100 1 LAP
2017 MTR
9-11yrs 2014- 2LAP 500+D 1000 1 LAP 2 LAP 500+D 1000 100 1 LAP
2015 MTR
11-14yrs 2011- 500+D 1000 1 LAP 1500M 500+D 1000 100 1 LAP 3000
2013 TR MTR
14-17yrs 2008- 500+D 1000 1 LAP 3000M 500+D 1000 100 1 LAP 5000
2010 TR MTR
Ab.17yrs 2007 500+D 1000 1 LAP 3000M 500+D 1000 100 1 LAP 5000
Above TR MTR
Note: Skater can take part in 2 out of 3 races IN 5-7 and 3 out of 4 races above 5-7 age groupsA skater can take part only in one speed
category i.e. Quads, Inline.

Note : Entry fee : 500/- ( Non-refundable)

The U.P.R.S.A. /Organizing Committee will not be held responsible for any compensation or otherwise in case
of any injury or loss of life. I have read and understood the rules and regulations governing the championship and
agree to abide by the same. I shall uphold sportsmanship and participate in the championship in the true spirit of
the game, shall uphold and be bound by the decision of the organizing committee.

Signature of the skater/parent

 RULES & REGULATIONS
1. Participants must report at the venue, before 15 minutes of race time.

2. The participants of all groups under 17 years must submit self- attested copy of
D.O.B certificate / School Bonafide certificate and RSFI Registration form.

3. The last date for receiving complete entries is 15th MAY 2024. Late fee amount Rs. 200/-
will be charged per skater for entries sent after 15th May. No entry will be accepted after
18th May, 2024. Entries will be received only on uprsaentries@gmail.com .

4. The organizing committee/association will not be held responsible for any compensation
orotherwise in case of any injury during the course of the championship.

5. A skater can take part in one category i.e. quad or inline.

6. The winners (first three positions) will personally collect the medals and certificates at the
closing ceremony.

7. All participants will wear SKINSUIT with the race number on lower back and left thigh.

8. Protest, if any must be lodged in writing within 15 minutes of the event (AFTER/BEFORE)
in question accompanied with a fee of Rs.2000/-, which will only be refunded if the protest
is Held valid. The final verdict is in hands of the Chief Referee. Any verbal protest will be
considered as insubordination to the Chief Referee and the organizers and will be treated
assuch.

9. A team manager’s meeting will take place at 4 pm on 24th MAY 2024 at the venue.

10. Date of Championship may change if required it will be the sole discretion decision of
Organizing Committee of UPRSA

Organizing Secretary Monitoring Committee UPRSA

Mr. Anil Kumar Mr. Shaurya Panchal
Contact no: 9911520900 Contact No. : 9311669989

Championship Co-ordinator
Mr. Deepanshu (7982012673)

Under the Supervision of UPRSA Discipline Committee UPRSA

Chairman STC: Mr Vijay Gadroo Mr. D.S. Rathore
Mr. Sandeep Bhatnagar
Mr. Shaurya Panchal

* For help please mail to upsa.rsfi@yahoo.com or organisingsecretaryuprsa@gmail.com