RiverVault2015
Athlete Information and Registration Form
Sponsored by the Shocker Track Club
USATF Sanctioned Meet
River Vault 2015 is a sanctioned pole vault competition held during the Wichita River Festival.
Competition will be sanctioned through USA Track & Field by the Shocker Track Club.
Certified Officials will conduct the events in accordance with USA Track & Field Rules.
June 6, 2015
Wichita River Festival
Century II Bob Brown Expo Hall Parking Lot on Main Street
(Park in Gander Mountain or Water Walk parking garages)
Competitions begin at 10:00 a.m.
Registration Fee - $40.00
Provides Event T-Shirt and River Festival Button
Registration now through the deadline of June 1, 2015
Registrant Packet Pick-up Begins June 1 through 4 at Wichita State Cessna Stadium Track at 630p
Late Registration Fee is $45 through June 3, 2015 and subject to availability
Separate competitions will be held for:
10:00 a.m. Start - Youth Girls and Youth Boys (Up to age 18)
1:00 p.m. Start - Open for Women and Men (ages 19 and up)
4:00 p.m. Start - Elite (high level competitors) for Women and Men
Trophies/Medals will be awarded to the top three finishers in each competition group
Make checks payable to Shocker Track Cluband mail with the completed registration form to:
Shocker Track Club
c/o Wichita State University Track and Field (River Vault 2015)
1845 Fairmount
Wichita, Kansas 67260
Questions?
Contact Denis Fraizer at 316-680-0852 or
River Vault 2015
Athlete Registration Form
NAME
ADDRESS
CITY STATE ZIP
PHONE PHONE
EMAIL 2015 USATF NO.
(membership is NOT required to compete)
CURRENT SCHOOL/CLUB COACH
AGE GENDER T-SHIRT SIZE (circle)SMLXLXXL
WOMEN’s/Girl’s COMPETITION CATEGORYYouth Open Elite
MEN’s/Boy’sCOMPETITION CATEGORY Youth Open Elite
PRs OUTDOORFTININDOORFTIN
EMERGENCY CONTACT PHONE
PHYSICIAN HOSPITAL
In consideration of being allowed to participate in RIVER VAULT 2015, the undersigned acknowledges, appreciates, and agrees that: 1. The risk of injury involved in this program is significant, including the potential for permanent paralysis and death, and while particular skills, equipment, and personal discipline may reduce this risk, the risk of serious injury does exist; and, 2. I knowingly and freely assume all such risks, both known and unknown, even if arising from the negligence of the releasees or others, and assume full responsibility for my participation; and 3. I willingly agree to comply with the stated and customary terms and conditions for participation. If, however, I observe any unusual significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the nearest official immediately; and, 4. I, for myself, and on behalf of my heirs, assign personal representatives and next of kin, hereby release and hold harmless The Shocker Track Club, Inc, their officers, officials, agents and/or employees, other participants, sponsoring agencies, advertisers, sponsors, and, if applicable, owners and lessors of premises used to conduct the event (“releasees”), and in particular, Wichita Festivals with respect to any and all injury, disability, death, or loss or damage to person or property, whether arising from the negligence of the releasees or otherwise. I have read this release of liability and assumption of risk agreement, fully understand its terms, understand that I have given up substantial rights by signing it, and sign it freely and voluntarily without any inducement. By signing below, I attest that I am physically fit and have trained sufficiently for this event. The Shocker Track Club, Inc. and its representatives, employees, and volunteers have permission to obtain immediate medical care and I consent to hospitalization, the performance of necessary diagnostic tests, the use of surgery, and/or the administration of drugs in an emergency. I understand that I am responsible for payment of medical expenses.
ATHLETE SIGNATURE DATE
Parent/Guardian SIGNATURE (if athlete is under 18) DATE
River Vault 2015
Athlete Information Form
For Meet Announcer
Complete only the fields you are willing to share!
NAMEAGE
Parent’s Names
Brothers/Sisters
Pets
ACCOMPLISHMENTS
HOBBIES
HIGH SCHOOL and/or COLLEGE ATTENDED
Seasons Best Jump LIFETIME PR
FAVORITE POLE VAULTER
Who is your favorite athlete?
What is your favorite song?
What is your favorite flavor of ice cream?
What is your favorite food to eat?
What is your favorite movie?
With whom would you rather eat dinner (Circle one)?
Renaud LavillenieBarack ObamaDenis Fraizer(if he buys!)My Coach
When I’m not pole-vaulting, I’m usually
Would you rather fight 100 duck sized horses or 1 horse sized duck? (Circle one)
100 duck sized horses1 horse sized duck