Saturday, April 9th, 2016 | 10:00AM
Saturday, April 9th, 2016 | 10:00AM – 1:00PM Behind WIU Tennis courts | West side of Brophy Hall Itinerary: 10:00AM Arrival/Check-In 10:10-10:20AM Introductions 10:30AM Station #1 10:50AM Station #2 11:10AM Station #3 11:30AM Station #4 11:50AM Station #5 **Subject to change with additional of stations/activities 12:10PM Completion of Stations Lunch Pictures with Rocky & Athletes ‘Post Game Interview’ Meet & Greet with WIU Student-Athletes 1:00PM WIU Baseball vs. Oral Roberts ----------------------------------------------------------------------Participant Name: _____________________________________________________________ Male or
Female (Circle)
Date of Birth: ___________________________
Address: ____________________________________________________________________ Phone: ___________________________
E-mail: ________________________________
T-shirt size: __________________________________________________________________ Specific Allergies: _____________________________________________________________ Informed Consent/Medical Release: The undersigned hereby releases any and all rights or claims for damages against Western Illinois University, it’s governing board, faculty, agents, and all individuals assisting in facilitating and conducting these activities, from and against any and all liability for any harm, injury, damage, claims, demands, actions, causes of action, costs and expenses of any nature which the participant may have of which may hereafter accrue to participant, arising out of or related to any loss, damage or injury.
Emergency Contact: ___________________________________________________________ Relation to Participant: _________________________ Phone Number: ___________________ Photo Release: The undersigned authorize and give full consent to the WIU CONNECKS program to copyright or publish all photographs in which he or she may appear while participating in any and all of their programs.
Participant’s Signature (if over 18): ________________________________________________ Parent/Guardian Signature (if under 18): ___________________________________________ Please return to Victoria Kappel @ [email protected] -or- mail to: WIU ATHLETICS – CONNECKS Attn: Jessie Lantz 1 University Circle – Western Hall 103 Macomb, IL 61455
Female (Circle)
Date of Birth: ___________________________
Address: ____________________________________________________________________ Phone: ___________________________
E-mail: ________________________________
T-shirt size: __________________________________________________________________ Specific Allergies: _____________________________________________________________ Informed Consent/Medical Release: The undersigned hereby releases any and all rights or claims for damages against Western Illinois University, it’s governing board, faculty, agents, and all individuals assisting in facilitating and conducting these activities, from and against any and all liability for any harm, injury, damage, claims, demands, actions, causes of action, costs and expenses of any nature which the participant may have of which may hereafter accrue to participant, arising out of or related to any loss, damage or injury.
Emergency Contact: ___________________________________________________________ Relation to Participant: _________________________ Phone Number: ___________________ Photo Release: The undersigned authorize and give full consent to the WIU CONNECKS program to copyright or publish all photographs in which he or she may appear while participating in any and all of their programs.
Participant’s Signature (if over 18): ________________________________________________ Parent/Guardian Signature (if under 18): ___________________________________________ Please return to Victoria Kappel @ [email protected] -or- mail to: WIU ATHLETICS – CONNECKS Attn: Jessie Lantz 1 University Circle – Western Hall 103 Macomb, IL 61455
