Officials Application Form
Alexander Durley Stadium
TSU Campus – Houston, Texas
Friday-Saturday, March 17-18, 2017
Please print or Type all information - Application must be postmarked on or before March 1, 2017.
Personal and Certification Information FIRST NAME
MI
LAST NAME
MAILING ADDRESS
CITY
STATE
CELL PHONE
GENDER
ZIP
HOME PHONE
EMAIL ADDRESS
ARE YOU SAFESPORT CERTIFIED?
Male□ Female□
Yes□ No□
HAVE YOU WORKED AT THE TSU RELAYS BEFORE?
IF YES, IN WHAT CAPACITY?
Yes□ No□ USATF CERTIFICATION #
Certification Level
2016 USATF MEMBERSHIP#
EMAIL IS OUR PRIMARY MEANS OF COMMUNICATION WITH OFFICIALS. It is very important that you provide an email address in the contact information above.
Officiating Preferences Please indicate the top five areas that you prefer to officiate? You must select at least five areas. Due to the length of the meet, you may be required to work more than one event. TRACK EVENTS □ Finish Line/Lap/Timing/Finish
FIELD EVENTS □ Throws
OTHER SPECIALIZATIONS □ Marshal/Steward
□
Clerk or Course/Call Room
□
Horizontal Jumps
□
Wind Gage Operator
Umpire
□
Vertical Jumps
□
Technical Manager
Starter/Recall/Start Coordinator
□
Elect. Measure Judge
□
Implement Inspector
Race Walk Official
□
Race Walk Judge
□
Multi-Escort
Announcer
□
Finish Lyn Laser
□
□
□
□
Do you have experience with Field Lynx: Throws □
Horizontal Jumps □
Vertical Jumps □
Availability to Officiate ___
Friday and Saturday, March 17 and 18
___
Friday Only, March 17
___
Saturday Only, March 18
Officials Application Form Page 2 Shirt Size Sm □
Med □
Lg □
XL □
2XL □
3XL □
4XL□
Waiver and Release of Liability I understand that as a volunteer official, who participates in this TSU Relays I am expected to work all days indicated on this application and be responsible for my own costs incurred for transportation, housing, meals, uniform, and personal entertainment. I will receive no direct compensation or other benefits in my capacity as a volunteer official for the TSU Relays and to the Texas Southern University Athletics Department hereinafter referred to as “the Parties”. I agree to not present myself to others as an employee of any or all of the Parties. I agree to and do hereby voluntarily assume any and all risks of bodily injury, including death and damage to my property arising out of me volunteering at the 66th TSU Relays on March 17-18, 2017. I also hereby release and discharge the Parties and their respective officers, employees, agents and representatives from any and all actions, claims or liability for bodily injury or property damage caused by, arising from or in any way connected with the TSU Relays or related activities, excepting only such liability arising from the gross negligence of the Parties. I have carefully read and fully understand the content of this agreement and authorization for release of information as needed for conduct of the meet and execute it freely and voluntarily. I am aware that this is a release of liability and a contract between the Parties and me. A facsimile copy or photocopy of this authorization shall be as valid as the original. I agree to abide by all regulations and requirements for participation as a support volunteer at the TSU Relays and hereby certify that all information contained on this acceptance form is true to the best of my knowledge. If this document is emailed , a copy of this document with my e-mail address will constitute my acceptance and will have the same legal ramifications as my legal signature.
Signature and Acknowledgement SIGNATURE OF APPLICANT – By signing below, I certify that the above information is accurate to the best of my knowledge
Date
Mail this form to: TSU Relays Officials, 3100 Cleburne Street, Houston, Texas or email to
[email protected] Relays Officials Chair Use Only
Date Received:
Approved By: