Stephen F. Austin State University
Lumberjack Homecoming 5K Fun Run or Walk
Benefiting the Dr. Raymond Lee Worsham Scholarship
EVENT INFORMATION
Location: Corner of Wilson and Starr across from Tennis Complex Distance: at least 5K (or approximately 3.1 miles)
Date: Saturday, October 29, 2011
Start Time: 8:00a runners, 8:10a walkers
Please be on site 15 minutes early to sig in, register if needed and get number and stretched.
Pre-Registration: received on or before October 12, 2011 (guaranteed a shirt)/On-Site Registration: starts at 7a on-site
Student: $10
Faculty/Staff/Alumni Member: $25
Community: $30
Sponsors: SFA Alumni Association, SFA Campus Recreation
Prizes: 1st& 2rd place for males and females for associates of SFA, 1 st & 2nd place males and females for non-SFA associates,
1st & 2nd overall guess your time, largest group participating, best homecoming themed outfit
Proceeds go to: Dr. Raymond Lee Worsham Scholarship for the Campus Recreation Department
Mail completed form to:
Brian Mills
PO Box 13016, SFA Station
Nacogdoches, TX 75965
Make checks payable to: SFA Alumni Foundation
PERSONAL DATA
Name of Participant: ____________________________________________________________________________________
Last
First
Middle
SFA CID #: ______________________________ (if applicable) Will you need any special assistance? Y N
Major/Minor (if a student): ________________________________________________________________________________
Department (if you work on campus): _______________________________________________________________________
Address: ______________________________________________________________________________________________
Phone : _______________________________
E-mail Address: ____________________________________________________
Status of Participant: Student
Faculty
Staff
 Alumni Other (Please Specify) ____________________
Are you running/walking as part of a group? Please list group here: _____________________________________________________
T-Shirt Size:
S
M
L
XL
XXL
XXXL Child Size _____
WAIVER OF LIABILITY (Note: participants under the age of 18 must have parent or legal guardian’s signature)
I and my child, if applicable and hereafter collectively referred to as “I”, am aware that participating in the 5K Run/Walk is a potentially hazardous activity, and I
should not participate unless physically able. I verify and warrant that I am medically fit to participate and voluntarily participate in this activity. I agree to abide by all
rules and decisions of the event officials and voluntarily assume all risks associated with participation in the event and any associated event or activities including but
not limited to falls, contact with participants, effects of weather such as high heat and humidity, walking trails, nature, bugs and insects, traffic, and road conditions; all
such risks being known and appreciated in consideration of acceptance of the entry fee. I hereby DISCHARGE, COVENANT NOT TO SUE, AND WAIVE ANY
AND ALL CLAIMS WHATSOEVER AGAINST AND FULLY RELEASE Stephen F. Austin State University, the Board of Regents, the State of Texas, their officers,
servants, agents and employees, the SFA Alumni Association, any event sponsors, volunteers or staff, and all promoters, and their representatives and successors
(RELEASEES), from any and all liability, claims, demands, actions and causes of action whatsoever arising out of or related to any loss, damage, or injury, including
death, that may be sustained by me, or to any property belonging to me, WHETHER CAUSED BY THE NEGLIGENCE OF THE RELEASEES, or otherwise while
participating in such activity, or while in, on or upon the premises where the activity is being conducted. I further agree to INDEMNIFY AND HOLD HARMLESS
RELEASEES from any loss, liability, damage or costs, including court costs and attorneys fees, due to my participation in this activity, WHETHER CAUSED BY
NEGLIGENCE OF RELEASEES or otherwise. I understand that the entry fees are not refundable and RELEASEES shall not be responsible for any medical expenses
associated with any injury I may sustain. I have read this agreement carefully and understand it and certify my agreement by my signature below.
__________________________________________________________________________________________________________
Printed Name
Signature
Date