UW-Stout CONNECT

Blue Devil Glow Run Registration - 2023

Chosen Name *

Last Name *

Email Address *

Name of Payee (if your registration fee is being paid by someone other than yourself)

If you are paying for other participants, it is your responsibility to make sure they receive this registration form to complete. Registration form must be complete prior to September 25 to be guaranteed a t-shirt.

Phone Number

T-shirt Size *

Small

Medium

Large

X-Large

XX-Large

XXX-Large

I am registering after Sept. 25

Please note that registrations submitted after Sept. 25, are not guaranteed a t-shirt due to vendor production timeline.

Please mark how you identify. *

UW-Stout Student

UW-Stout Employee

UW-Stout Alumni

Community

Please select the statement that best describes you *

I am AT LEAST 18 years of age

I am UNDER 18 years of age

I UNDERSTAND THAT I AM BEING ASKED TO READ THE FOLLOWING DOCUMENT CAREFULLY. I UNDERSTAND THAT IF I WISH TO DISCUSS ANY OF THE TERMS CONTAINED IN THIS AGREEMENT, I MAY CONTACT UW-STOUT SAFETY & RISK MANAGEMENT SERVICES, AT 715-232-2258 OR 715-232-1793. *

By checking this box I understand the above statement.

I, for myself, my heirs, my children, my parents, assigns, personal representative and estate agree to defend, hold harmless, indemnify and release the Board of Regents of the University of Wisconsin System, the University of Wisconsin-Stout, and their officers, employees, agents and volunteers, from and against all claims, demands, expense (including costs and attorneyÔÇÖs fees), actions or causes of action of any sort on account of damage to personal property, or personal injury, or death which may result from my participation the University Recreation Program. This release includes claims based on negligence of the Board of Regents of the University of Wisconsin System, the University of Wisconsin-Stout, and their officers, employees, agents and volunteers, but expressly does not include claims based on their intentional misconduct or gross negligence.

Participation with the University Recreation Program is completely voluntary. The University of Wisconsin-Stout is not responsible for injuries or other health problems that may occur while participating in the center or using the center facilities or equipment. I also realize that the Blue Devil Glow Run is a high-risk sport and I could be injured. Each participant is advised to carry his/her own health and accident insurance. *

By checking this box I understand and agree with the above statement

Consent for emergency treatment:

I authorize University Recreation and its designated representatives the authority to act in any attempt to safeguard and preserve my health and safety during my participation. I consent, on my behalf, to any emergency medical/hospital care or treatment to be rendered upon the advice of any licensed physician. I AGREE TO BE RESPONSIBLE FOR ALL NECESSARY CHARGES INCURRED BY HOSPITALIZATION OR TREATMENT RENDERED PURSUANT TO THIS AUTHORIZATION. I DO NOT PRESUME THAT ANY INSURANCE, WHETHER FOR ACCIDENT, LIFE, MEDICAL, OR PROPERTY LOSS HAS BEEN SECURED FOR MY BENEFIT. I UNDERSTAND THAT UNIVERSITY RECREATION HAS ADVISED ME TO SEEK THE ADVICE OF MY PHYSICIAN BEFORE PARTICIPATING IN THIS ACTIVITY. *

By checking this box I understand and agree with the above statement

Photo/Media Release:

I grant University Recreation the right to use, reproduce, assign and/or distribute photographs, films, and videotapes of myself for use in materials they may create. *

By checking this box I understand and agree with the above statement

The signature below verifies that the above statements have been read and agreed upon. *

Parent/Guardian Signature *