Participant Registration Form

Transcription

1 Stephen F. Austin State University Sport Club Program Participant Registration Form Name: Sport Club: Local Address: Primary Address: Non SFA Student ID #: Phone #: Academic Year: Graduation : Emergency Contact Information Name: Phone Number: Relationship: Driver Information Do you plan to drive for the club? Y N Car Information: Make: Model: License Plate #: Driver's License #: Driver's License State: Auto Insurance Information: Company: Policy #: Health Insurance Information: Does your league offer an insurance policy? Y N Company/League Name: Policy #: Affirmation, Waiver, and Liability Release In consideration of the permission given to me by Stephen F. Austin State University to participate in the above-described activity, I, (for myself, my heirs, executors, and administrators), release, discharge, and agree to indemnify SFA, the supervisors named above, and all of the university s regents, officers, agents, and employees ( the released parties ) from any and all liability arising from or in connection with my participation in the above-described activity, regardless of whether such liability is caused by the negligence of the released parties. I intend that the indemnity provided in this waiver and release is indemnity by no to indemnify the released parties from the consequences of their negligence, whether that negligence is the sole or a concurring cause of the liability. I have been informed and understand the risks and danger inherent in the above-described activity and that I participated freely and without guarantee or compulsion. I am of lawful age and legally competent and empowered to execute this affirmation, waiver, and release on my own behalf. Name (Print First, Last) Signature

2 What is your current G.P.A.?** **If you are a freshman, please put N/A What is your major? Were you a member of this club in the previous semester? How did you find out about your sport club team? (Check all that apply) Y N SFA Sport Club Website Friends Current Players Freshman Orientation Former or Current Coaches SFA Staff Flyer/Handbill Saw Club Practicing Other (Please Explain) Did having a sport club team influence your decision to enroll at SFA (Please mark one that applies)? N/A How has participating on a sport club team affected your overall academic performance? Negatively No Affect Positively N/A Has participating on a sport club team made a difference in your decision to stay enrolled at SFA? N/A Do you believe you are representing SFA by participating on a sport club team? N/A Do you believe there are leadership opportunities available when participating on a sport club team? N/A Does your club require you to pay dues? How much do you pay in club dues? Y N $0-$ $ $ $ $ Over $ N/A Please circle three from the list below that you expect to gain from the club this semester: Event Planning Teamwork Competitiveness Confidence Conflict Resolution Leadership Practice Planning Increased Technical Skills in Sport Time Management Other: (Please Explain) Interpersonal Communication Budget Planning Better Conditioning More Involved within Campus Rec Winning Financial Responsibility Travel I Just Want To Play Public Speaking Make Friends Learn a New Sport/Activity I Want To Be An Officer

3 STEPHEN F. AUSTIN STATE UNIVERSITY SPORT CLUB PROGRAM WAIVER OF LIABILITY AND HOLD HARMLESS AGREEMENT 1. In consideration for participating in (Sport Clubs) and other valuable consideration, I hereby RELEASE, WAIVE, DISCHARGE AND CONVENANT NOT TO SUE Stephen F. Austin State University (SFA), the Board of Regents, the State of Texas, their officers, servants, agents, and employees (hereinafter referred to asreleasees) from any and all liability, claims, demands, actions and causes of action whatsoever arising out of or related to any loss, damage, or injury, including death, that may be sustained by me, or to any property belonging to me, WHETHER CAUSED BY THE NEGLIGENCE OF THE RELEASEES, or otherwise, while participating in such activity, or while in, on or upon the premises where the activity is being conducted or in transportation to and from said premises. 2. To the best of my knowledge, I can fully participate in this activity. I am fully aware of risks and hazards connected with the activity, including but not limited to the risks as noted herein, and I hereby elect to voluntarily participate in said activity, and to enter the above-named premises and engage in such activity knowing that the activity may be hazardous to me and my property. I VOLUNTARILY ASSUME FULL RESPONSIBILITY FOR ANY RISKS OF LOSS, PROPERTY DAMAGE OR PERSONAL INJURY, INCLUDING DEATH, that may be sustained by me, or any loss or damage to property owned by me, as a result of being engaged in such an activity, WHETHER CAUSED BY THE NEGLIGENCE OF RELEASEES or otherwise. 3. I further hereby AGREE TO INDEMNIFY AND HOLD HARMLESS THE RELEASEES from any loss, liability, damage or costs, including court costs and attorney s fees, that may incur due to my participation in said activity, WHETHER CAUSED BY NEGLIGENCE OF RELEASEES or otherwise. 4. It is my express intent that this Release and Hold Harmless Agreement shall bind the members of my family and spouse (if any), if I am alive, and my heirs, assigns and personal representative, if I am not alive, shall be deemed as a RELEASE, WAIVER, DISCHARGE AND COVENANT NOT TO SUE the above named RELEASEES. I hereby further agree that this Waiver of Liability and Hold Harmless Agreement shall be construed in accordance with the laws of the State of Texas. 5. I UNDERSTAND THAT THE UNIVERSITY WILL NOT BE RESPONSIBLE FOR ANY MEDICAL COSTS ASSOCIATED WITH AN INJURY I MAY SUSTAIN. 6. I further agree to become familiar with the rules and regulations of the University concerning student conduct and not to violate said rules of any directive or instruction made by the person or persons in charge of said activity and that I will further assume the complete risk of any activity done in violation of any rule or directive or instruction. 7. I also understand that I should and am urged by SFA to obtain adequate health and accident insurance to cover any personal injury to myself which may be sustained during the activity or the transportation to and from said activity. 8. I ALSO UNDERSTAND THAT THE PARTICIPANTS ARE INDIVIDUALLY RESPONSIBLE FOR DAMAGE TO THE FACILITIES AND THE ATTENDING SPONSOR SHALL BE RESPONSIBLE FOR SUPERVISION OF PARTICIPANTS ATTENDING WITH SAID SPONSOR. SFA IS NOT RESPONSIBLE FOR SUPERVISION OF PARTICIPANTS. INITIALS PHOTO/VIDEO DISCLAIMER SFA Campus Recreation reserves the right to use any photograph/video taken at any Campus Recreation-sponsored event or program, without the expressed written permission of those included within the photograph/video. Photographs/videos may be used in publications or other media material produced, used or contracted by Campus Recreation including but not limited to: flyers, brochures, newspapers, magazines, television, websites, etc. Any person desiring not to have their photo taken or distributed must contact the Coordinator for Promotions in writing of his/her intentions and include a photograph. We will use the photo for identification purposes and will hold it in confidence. INITIALS

4 POSSIBLE INJURIES WHICH MAY OCCUR There are risks involved when participating in the following sports program offered: (Sport Clubs). Some of the possible injuries and bodily harm which can occur through participation in the programs are listed below. This list is provided to make the prospective participant aware of the possibilities of injuries which may be sustained. The individual is completely responsible for his/her own safety and health. POSSIBLE INJURIES: strains, sprains, pulls, tears, cramps, infection, rashes, vomiting, bruises, contusions, wounds (abrasions, incisions, lacerations, punctures, avulsions), insect bites, dislocation, blisters, nosebleeds, broken bones, fractures, choking, respiratory or heart failure, heat exhaustion, heat stroke, fainting, nerve damage, shock, paralysis, concussion, and in an extreme case-death. BODY AREAS WHICH MAY BE AFFECTED OR INVOLVED IN SPORTS INJURIES: head, face, eye, ear, jaw, teeth, mouth, neck, nose, chest, abdominal, back, arms, elbow, hands, fingers, wrist, shoulders, genital organs, scalp, bones, leg, knee, hip, ankle, feet, toes, internal organs, nerves, muscles, ligaments, cartilage, joints, tendons, spinal cord, arteries and veins, brain. I/my child have reviewed the above information and am aware of the risks in participating in sports programs and the possible injuries which may occur. I/my child freely and voluntarily agree to participate in any and/or all of the activities listed here which are offered in the (Sport Clubs). IN SIGNING THIS RELEASE, I ACKNOWLEDGE AND REPRESENT THAT I have read the foregoing Waiver of Liability and Hold Harmless Agreement, understand it and sign it voluntarily as my own free act and deed; no oral representations, statements or inducements, apart from the foregoing written agreement, have been made; I am at least eighteen (18) years of age and fully competent; and I execute this Release for full, adequate and complete consideration fully intending to be bound by same. INITIALS IN WITNESS WHEREOF, I have hereunto set my hand on this day of, 20. MEDICAL TREATMENT PERMISSION FORM *Only necessary to complete if the participant is under the age of 18. Student s Name I,, Parent or guardian of the above named minor, hereby give my permission, consent and authorization for any medical treatment deemed necessary by a hospital or physician. I appoint the event coordinator and/or director my lawful agent with power to authorize and consent to the administration of medical treatment during the aforementioned event. School Alternate Phone ( ) Participant Parent must sign if under 18 years old Home Phone ( ) Health Carrier Please list all allergies, restrictions or health exceptions. This form should be properly signed and turned in at the time of registration. In case of such accident or illness, I give permission for my child to be given medical treatment as deemed appropriate. I will assume responsibility for any medical treatment as deemed appropriate. I will assume responsibility for any medical bills incurred by my child. Parent or Legal Guardian Signature My child has been examined by a family physician, and is physically able to participate in the (Sport Clubs). Parent or Legal Guardian

5 Stephen F. Austin State University- Sport Clubs Anti-Hazing Agreement Students who participate in the Stephen F. Austin State University Sport Clubs program at Stephen F. Austin State University are strictly prohibited from engaging in any type of hazing activity. Texas Anti-Hazing Law, to and Class B misdemeanor, Class A if results in bodily injury. State felony if results in death. An organization may be fined if it condones hazing. Medical personnel receive immunity from liability for reporting an incident of hazing if the report is made in good faith. Statutes apply the secondary educational institutions and institutions of higher learning only. Hazing is a violation of the Stephen F. Austin State University Student Code of Conduct: The student Code of Conduct refers to hazing as Any intentional, knowing or reckless act occurring on or off campus by one person alone or acting with others, that endangers the mental or physical health or safety of a currently-enrolled or prospective student for the purpose of new member intake, being initiated into, affiliating with, holding office in, or maintaining membership in that organization. Hazing acts include but are not limited to: 1. Any type of physical brutality such as whipping, beating, striking, branding, electronic shocking, placing a harmful substance on the body, or similar activity; 2. Any type of physical activity such as sleep deprivation, exposure to the elements, confinement in a small space, calisthenics or other activity that subjects the student to an unreasonable risk of harm or that adversely affects the mental or physical health or safety of the student; 3. Any activity involving consumption of a food, liquid, alcoholic beverage, liquor, drug or other substance that subjects the student to an unreasonable risk of harm or that adversely affects the mental of physical health of the student; 4. Any activity that intimidates or threatens the student with ostracism, that subjects the student to extreme mental stress, shame, humiliation, that adversely affects the mental health or dignity of the student or discourages the student from entering or remaining registered at the institution, or that may reasonably be 5. Any activity that induces, causes, or requires the student to perform a duty or task which involves a violation of the Penal Code. Violations of this hazing agreement or Stephen F. Austin s hazing definition or student code of conduct include, but are not limited to: 1. Engaging in hazing; 2. Soliciting, encouraging, aiding or directing another engaging in hazing; 3. Intentionally, recklessly or knowingly permitting hazing to occur; 4. Having first-hand knowledge that a specific hazing incident is being planned or has occurred and failing to report said knowledge in writing to the judicial officer. ** An organization commits an offense if the organization condones or encourages hazing or if an officer or any combination of members, pledges, or alumni of the organization commits or assists in the commission of hazing. Individuals or groups seeking additional information about this policy or reporting possible violations should contact the Coordinator for Sport Clubs at (936) I have read and understand the Anti-Hazing Policy of Stephen F. Austin State University and agree to uphold the policy within my organization. Printed name Organization Signature

6 By signing below, I affirm to the following: Stephen F. Austin State University Sport Club Program Driver Consent Form Do you plan to drive for the club? Y N ***If no, it is not necessary to complete this page. As a member of the (name of club) Club, I voluntarily agree to drive myself and other members of the club to and from club sanctioned events during the current academic year to represent Stephen F. Austin State University. Initial I am at least 18 years of age and possess a valid Texas driver s license and possess personal automobile insurance coverage as mandated by the State of Texas. I will allow only authorized drivers to drive my vehicle while on the trip. I agree to keep a copy of my up-to-date driver s license and automobile insurance card with the SFA Sport Clubs Office. While driving, I agree to obey all local, state, and federal traffic laws; agree not to drive under the influence of alcohol or any illegal drug, agree not to possess or transport alcohol, illegal drugs, firearms or weapons; agree to wear a seatbelt and require all passengers to wear a seatbelt; and agree to avoid horseplay, racing, or other distracting or aggressive behavior. I understand that if my driver's license is suspended, is no longer valid, or I am cited for DUI, I agree to notify the Coordinator for Sport Clubs immediately and to indicate that I am no longer able to drive. I understand that if I fail to notify the Coordinator for Sport Clubs for a suspended driver's license or a DUI citation, and I drive a rental or personal vehicle (with club members), on behalf of myself, my heirs, executors, administrators, insurers, and assigns, I agree to defend, indemnify, and hold Stephen F. Austin State University and the state of Texas harmless from any and all injuries to me, including death, that occur while I am driving. Failure to notify the Coordinator for Sport Clubs of a suspended driver's license or DUI citation may also lead to further disciplinary action up to and including removal from the club. In addition, if voluntarily agreeing to drive a personal vehicle, by signing below I affirm that: I understand that by using my personal vehicle to drive myself and other sport club participants to any event, should there be any damage to my vehicle or injury to passengers in my vehicle, that my personal insurance will be used to cover any claims made. Neither the state of Texas, nor Stephen F. Austin State University, nor the Department of Campus Recreation will be responsible for damages or injuries. I also affirm by signing below that my vehicle has current state inspection and registration. I certify that the statements made by me on this form are true, complete, and correct to the best of my knowledge and belief and are made in good faith. Print Name Club Name Signature

7 Office Use Only SC Approval: Received: Participant Registration Form: Y N Hazing Agreement: Y N Waiver: Y N Car Insurance: Y N Personal Insurance: Y N Notes: Points Awarded Y N Updated Initials