NATIONAL WHEELCHAIR BASKETBALL ASSOCIATION
2014-2015 OFFICIAL TEAM OR CLUB REGISTRATION AND ROSTER
Name of Team __Wild Wheels_____________ Conference Arkansas Valley________________________
Division _______3______________ Official Team Representative _Craig Blanchard and/or Robert Rouse
_5681 Hwy 16 East Elkins, AR 72727 nwawildwheels@gmail.com ________________
City
State
Zip Code
E-mail Address
Phone Day _479 586 0285_____________ Night _______________
Name
Classification
Gender Mailing Address
Birth
Date
Craig Blanchard
55
Curt Howell
43
Jason Long
5
2
M
10/29/70
1
M
3
M
Robert Rouse
11
1
M
Jeremy Smith
34
3
M
Richard Marting
18
3
M
Jerry Breedlove
33
Jake Geisler
23
3
M
2
M
5681 Hwy 16 East
Elkins, AR 72727
609 West Dickson
Fay., AR 72701
1 Sherington ln
Bella Vista, AR
72714
20874 Justin dr.
Springdale, AR
72764
128 Center Point
Centerton, AR
72719
2200 E Mountain
E N103
Springdale, AR
72764
103 North Ninth St
Jasper, AR 72641
603 SW Wallstone
Road
Bentonville AR
72712
Fax _______________
TShirt
Size
L
Military Disability
Veteran
# of Years Played
No
Paraplegia
20
M
No
Quadriplegia
15
9/4/87
2/26/69
L
Yes
Amputee
3
2/11/69
2XL
No
Paraplegia
5
4/24/78
Xl
No
Brain injury
2
7/16/72
M
No
Amputee
2
10/9/48
XL
Yes
Amputee
3
04/20/92
2XL
No
Paraplegia
16
Name
Classification
Gender Mailing Address
Joel Raseon 16
2
M
Matt Dalbec 44
2
M
Staff
803 N 11th St.
Rogers, AR 72756
4005 SW
Carriageway Ave.
Bentonville, AR
72712
Address, City, State, Zip
Birth
Date
Military Disability
Veteran
# of Years
Playing
7/16/05
TShirt
Size
M
No
Spina Bifida
New
11/23/81
XL
No
Paraplegia
7
Title or responsibility to team
Completed by ________Craig Blanchard Coach/Player ____________________
Signature of Officer
Title