Please complete all information completely and
accurately. On-line Registration closes Monday, September 21 at noon.
The event is free to all students (elementary, secondary, and
Shawnee State), SSU faculty/staff, alumni, and Golden Bears.
For all other pre-registrants, the fee is $15.00 payable the day of
the race.
| Name: |
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| Email: |
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| Address: |
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| Phone Number: |
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| Age on race date: |
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Activity (select one): |
Run
Walk |
| Gender: |
Male
Female |
| Check Applicable: |
SSU
Student
SSU Alumni
Golden Bear
SSU Faculty
Staff |
| T-Shirt Size
(select one): |
Child
10-12
Child
14-16
Adult
S
Adult
M
Adult
L
Adult
XL
Adult
XXL
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| ASSUMPTION OF
RISK AND RELEASE OF LIABILITY FORM |
I understand that Shawnee State
University (“Shawnee State”) is providing me with the
opportunity to participate in the following
athletic/physical activity Shawnee State Bear Run (the
“Activity”) (for this form, the term “Activity” shall
also include all travel to and from the Activity).
In consideration for being allowed to participate in the
Activity, I knowingly and voluntarily:
• acknowledge and understand that my participation in
the Activity is entirely voluntary;
• acknowledge that there are risks and hazards which may
arise from participation in this Activity, and I
acknowledge that my participation in this activity may
result in injury (serious and minor), loss of life,
and/or loss of property;
• acknowledge the risks and hazards involved may
include, but are not limited to, falling, slipping,
tripping, holes, uneven pavement, mud, ice and/or other
participants;
• acknowledge that Shawnee State University (“Shawnee
State”) is not legally responsible for my personal
safety or the safety of my property during the Activity;
• acknowledge that I have: (i) had a physical
examination and have been given my physician’s
permission to participate, or (ii) I have decided to
participate in Activity without the approval of my
physician;
• represent that I am physically and psychologically
ready to participate in Activity;
• acknowledge that, if I am a Shawnee State employee,
the Activity is not within the course and scope of my
employment with Shawnee State. I specifically
acknowledge that my waiver below shall include rights to
workman’s compensation benefits for any injury or
disability incurred while participating in such
Activity;
• acknowledge that any Shawnee State personnel or agents
attending the Activity are not necessarily medically
trained to care for any physical or medical problems of
individuals participating in the Activity;
• represent that I have adequate health and
hospitalization insurance for any injuries that I may
receive as a result of my participation in the Activity;
and
• agree to follow all the safety procedures and
instructions of the Activity coordinators (e.g.,
appropriate dress, proper use of safety equipment,
etc.).
On behalf of myself and my heirs and assigns, I
knowingly and voluntarily assume all risks associated
with the Activity and release Shawnee State, its
trustees, officers, employees and agents (collectively
“Shawnee State Parties”) from any and all responsibility
or liability for personal injury, emotional injury,
death or property damage sustained by me during or
because of my participation in the Activity. I agree,
for myself, my administrators, personal representatives,
executors, predecessors, successors, agents, heirs and
assigns to release and hold harmless the Shawnee State
Parties from any present or future claim for personal
injury, emotional injury, death or property damage
arising directly or indirectly from my participation in
the Activity, to the fullest extent permitted under law,
including allegations or claims of negligence on the
part of the Shawnee State Parties, provided, however,
this form does not apply to acts of gross negligence,
willful or wanton conduct, or intentional conduct.
I UNDERSTAND AND AGREE THAT BY SIGNING THIS FORM I WILL
WAIVE AND FOREVER RELINQUISH ANY AND ALL CLAIMS THAT I
MAY HAVE, WHETHER KNOWN OR UNKNOWN, AND WHETHER
ANTICIPATED OR UNANTICIPATED, AGAINST THE MAIMI PARTIES
ARISING OUT OF MY PARTICIPATION IN THE ACTIVITY.
I understand and agree that if I am signing this form on
behalf of my minor child, that: (i) I will be giving up
the same rights for the minor as I would be giving up if
I signed this document on my own behalf, and (ii) I
personally represent and warrant that I am authorized to
sign the form on behalf of the minor.
Fields
marked in RED with *asterisks* below are required in
order to officially participate in this race!
*Signature:
*Date:
*Name (Printed):
*Telephone:
* Street
Address:
* City, State, Zip
Parental/Legal Guardian Co-Signature (if under18):
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| Several Award Categories have been
changed. The complete list of award categories is
below: |
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| RUNNERS |
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| Women |
Men |
| 8 & under |
8 & under |
| 9-10 |
9-10 |
| 11-12 |
11-12 |
| 13-15 |
13-15 |
| 16-18 |
16-18 |
| 19-24 |
19-24 |
| 25-29 |
25-29 |
| 30-39 |
30-39 |
| 40-49 |
40-49 |
| 50-59 |
50-59 |
| 60+ |
60-69 |
| |
70+ |
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| WALKERS |
|
| Women |
Men |
| 12 & under |
12 & under |
| 13-29 |
13-29 |
| 30-49 |
30-49 |
| 50-59 |
50-59 |
| 60-69 |
60-69 |
| 70+ |
70+ |
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| Special Categories |
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| Faculty/Staff |
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| Students |
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| Alumni |
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