USATF Certification Level: Apprentice Association National Master

NAME: First name Last name ADDRESS Click here to enter text. CITY Click here to enter text. State and zip code Click here to enter text. PHONE Click here to enter text. CELL Click here to enter text. EMAIL Email Address required

USATF Officials Certification #: _Click here to enter text.__USATF Membership #: _Click here to enter text.

USATF Certification Level: ☐ Apprentice ☐ Association ☐ National ☐ Master

Shirt size (Men’s sizes) ☐ XS ☐ S ☐ M ☐L ☐ XL ☐2X ☐ 3X ☐ 4X

Housing needed: ☐ Tuesday 2/24 ☐ Wednesday 2/25 ☐ none

Assignments The CUSA LOC will pick the Starters, Referees and Announcers. The available positions are listed below. Please indicate your preference from highest priority to lowest; 1 through 5. Depending upon the flow of the meet and the time your event completes, if needed you may be assigned to be a lap counter or additional umpire.

# Clerk of Course # High Jump # Start line Clerk # Finish Line # Umpire # Laserlynx date certified Click here to enter text. # Marshall # Fieldlynx date certified Click here to enter text. # Throws # Implement Inspector # Pole Vault # Spike Checker # Horizontal Jumps Experience List below, starting with the most recent, six significant competitions you have officiated. Prior experience will influence assignments and your first selection for assignment may not be your meet assignment.

Month/Year Meet Name Officiating Duty (indicate head or crew) Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text.

Waiver and Release of Liability I understand that if I am selected I will be working as an official, I do agree and do hereby voluntarily assume any and all risks of bodily injury, including death and damage to my property arising out of my participation caused by my conduct. I also hereby release and discharge the CUSA and their respective officers, employees 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 any participation or related activities during the meet caused by my conduct. This waiver and release are not interpreted to release or require me to indemnify any entity or individual whose conduct I have no control for its or their negligence, gross negligence or deliberate conduct that results in injury to me anyone else who is injured. I hereby declare that I am in good health and capable of carrying out any officiating duties for the assignments I seek, unless otherwise noted here:

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I have carefully read and fully understand the content of this agreement and authorization for release of information needed for conduct of the meet and execute it freely and voluntarily. I am aware that this application contains a release of liability and a proposed contract between the parties and me. I agree to abide by all regulations and requirements for participation as an official at the said championships and hereby certify that all the information contained on this form is true to the best of my knowledge. If emailed, a copy of the document with my email address will constitute my acceptance and will have the same legal ramifications as my signature.

Signature: Click here to enter text. Date: Click here to enter text. signature of applicant

Please return the completed application to: Steve Luper at: [email protected].