3rd Annual NIU Grad Sport Society “Rise and Run”
5K Race Registration Form
SUNDAY, May 3, 2015 ▪ Start Time: 8:00am ▪ West Parking Lot of Huskie Stadium
RACE INFORMATION:
Name:
West Parking Lot of Huskie Stadium
Northern Illinois University
DeKalb, Illinois
GSS “Rise and Run” 5K Race Website
Address:
City:
State:
Phone:
Email:
Zip:
DATE: Sunday, May 3, 2015; 8:00am
(required for confirmation and updates)
Birthdate:
Gender:
Female
Male
(required for age group classification)
CHECK-IN TIME:
 Sunday, May 3
ENTRY FEE:
 Before April 21*
 April 22-28*
 April 29-May 3
Indicate SM Grad Student Reference Name (if applicable):
*
Shirt Size (check one):
XS
S
M
L
XL
XXL
6:30-7:45am
Plan to bring shoes:
Yes
No
**
Return Completed Form, Signed Waiver (below), and Registration Fee To:
Steven Howell
Make checks payable to Grad Sport Society
Northern Illinois University
Department of KNPE
Total Amount Enclosed: $
*Fair market value is $15 and is tax deductible as allowed by law as we operate as a 501(c)(3)
DeKalb, IL 60115
$20/$15**
$25/$20**
$30/$25**
Entries must be postmarked by 4/21 to ensure tshirt (and appropriate size)
$5 off with donation of used shoes; limit 1 pair per
runner (shoe limit only applies to discount)
TO REGISTER ONLINE:
http://tinyurl.com/GSS5k2015
(will redirect you to our online registration site)
QUESTIONS:
Contact Steve Howell at
[email protected] or (815) 753-1157
RACE PROCEEDS TO BENEFIT
adventureworksdekalb.org
hopehavendekalb.com/
tinyurl.com/BYSCNIU
tinyurl.com/gradsportsoc
ASSUMPTION OF RISKS AND LIABILITY RELEASE AGREEMENT
The Northern Illinois University (NIU) Grad Sport Society is coordinating a 5K run/walk (hereafter, “Program”). The terms of this Assumption of Risks and Liability Release Agreement (hereafter
“Agreement”) are required as a condition of participation in the activity Program. This Agreement shall be construed in accordance with and governed by the applicable law of the State of Illinois.
ASSUMPTION OF RISK: As a Participant in this Program, the undersigned Participant expects to take part in physical activity, which may create foreseeable or inherent risk of injury to his/her person
and/ or property. The specific risks vary from one activity to another, but can range from, (1) minor injuries such as scratches, bruises, sprains and embarrassment, (2) major injuries such as joint or back
injuries, broken bones, heart attacks, head injuries, and psychological trauma, (3) devastating injuries including paralysis and death. Participants acknowledge the University is an element of Illinois State
government and it undertakes no direct legal or financial responsibility for Participant’s personal safety or well-being when participating in activities during the course of the program. Participant agrees to
assume those risks in this Program that may cause him/her respective bodily injury or loss and personal property damage or loss that may arise during and/or as a result of the Participant’s participation in this
Program.
SPECIAL MEDICAL INSURANCE AND CONSENT NOTE: Participants must arrange their own personal medical care insurance as NIU does not provide commercial medical expense
coverage, except through the terms and conditions of the student health insurance program. Participants also understand and agree that NIU or Program staff may need to respond to accidents and potential
emergency situations. By their respective signature below, Participants hereby give their consent for any medical treatment that may be required during their participation with the understanding that the cost
of any such treatment will be their respective responsibility.
RELEASE OF LIABILITY: In consideration of NIU’s accepting Participant into the Program, Participant, his/her heirs, executors, administrators, employers, agents, representatives, insurers, and
attorneys, to the fullest extent allowed by law do hereby release and discharge Northern Illinois University, its Board of Trustees, any NIU department, or administrative, employees, and agents, as well as the
City of DeKalb and its representatives, officer, employees, and agents from any and all claims and causes of action for Participant’s bodily injury or loss and personal property damage or loss that may arise
during and/or as a result of Participant’s participation in the Program conducted by or under the control of a unit of Northern Illinois University, in the absence of NIU’s gross negligence. Additionally, the
undersigned Participant grants to the Program, its representatives and employees the right to take photographs of me and my property in connection with the above-identified subject. I Participant authorizes
the Program, its assigns and transferees to copyright, use and publish the same in print and/or electronically. Participant agrees that the Program may use such photographs with or without Participant’s name
and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content.
Participant acknowledges that she/he has read this Assumption of Risks and Liability Release Agreement and that she/he understands its meaning and effect. Terms of Agreement Accepted by or on behalf of:
Signature of Participant
Date
Signature of Parent or Guardian (if participant is under 18)
Date