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ORU Vaultober Costume Pole Vault event
Saturday October 24, 2009 Registration Begins at 12pm Vaulting begins at 1pm
*Must wear a costume to vault! All heights and ages are welcome to participate
$5 Donation Enters You A Chance to win Fabulous prizes (2) $50 Polo Grill gift card $100 Tulsa Runner Gift Card Qdoba gift certificates Cici’s gift certificates Autographed Joe Dial pole vault pole And many more!!
$25 Athlete entry Fee $1 Children 13 & under $2for Students $3 for Adults
Oral Roberts University 7777 South Lewis Avenue Tulsa, OK - Located in the new indoor baseball/track facility
QUESTIONS: e-mail
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2009 Costume Vault Registration Form
Name: _______________________________ M F Age: _________ Street Address: ___________________________ City: ___________________________ State: __________Zip: _____________ DOB: _____/______/______
Any medical concerns we should be aware about? __________________________________________________________________________
Parent’s or Legal Guardian’s Name: _______________________________ Phone Number: _______________________________
School: ______________________________ Grade: ______________________________ Personal Record: ______________________ Costume:__________________________________________________________________
Register before OCTOBER 24th and have your name entered into the
raffle drawing for one of our many PRIZES!
$25 Registration Fee – Check or Cash Send Payment to: ORU Track & Field Oral Roberts University 7777 South Lewis Avenue Tulsa, OK 74171 Attn: Joe Dial
Risk Acknowledgement
To the Parents or Guardians:
I _______________________________ acknowledge and know that there is risk involved in the pole vault and that it is a potentially hazardous activity. I understand that the ORU Track and Field team will take precautions to minimize that potential. I do hereby waive, release and discharge all claims of whatsoever kind which I may have, or which may hereafter arise against ORU, its proprietors, its agents or employees.
Parent Signature ____________________________________Date _______________
Emergency Treatment
In order for your child to receive prompt medical treatment in the event of an accident during pole vault camp, we at ORU require that we have on hand a signed statement allowing your son or daughter to be treated in emergency situations. In all situations that may occur you will be contacted and informed of any treatment that is being done. Please provide us with a contact phone number where you can be reached.
In event of my son or daughter _____________________________________ is injured and in need of emergency medical treatment, I hereby give permission for such treatment.
Parent signature ______________________________ Home _____________________ Cell _______________________ Work _______________________ Insurance Company _____________________________ Policy number ________________________ Emergency person if you can not be reached ________________________Phone _________________
Any questions please call: 918-495-6839 or 918-557-9754 jdial@oru.edu or sdial@oru.edu
Please Sign and Return To: ORU Track & Field Oral Roberts University 7777 South Lewis Avenue Tulsa, OK, 74171 Attn: Joe Dial
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