Auburn University Club Sports Assumption of Risks, Informed Consent, Waiver and Hold Harmless Agreement

Transcription

1 PARTICIPANT INFORMATION Name of Participant: Address: AU ID Number City: State: Zip: Phone Number: of Birth: Gender: M F Medical Insurance Carrier: Auburn University Club Sports Assumption of Risks, Informed Consent, Waiver and Hold Harmless Agreement Medical Insurance Policy Number: CLUB SPORTS INFORMATION Please check ALL Auburn University Club Sports in which you will be participating: Badminton Bass Fishing Climbing Cricket Cycling Golf Ice Hockey Karate Lacrosse (M) Lacrosse (W) Rowing Rugby (M) Rugby (W) Sailing Soccer (M) Soccer (W) Swimming Table Tennis Team Handball Tennis Ultimate Frisbee (M) Ultimate Frisbee (W) Volleyball (M) Volleyball (W) Water Polo Water Skiing Wrestling Semester(s) in which you will be participating in the(se) sport(s): Fall 2015 Spring 2016 ASSUMPTION OF RISKS, INFORMED CONSENT, WAIVER AND HOLD HARMLESS AGREEMENT PLEASE READ THIS DOCUMENT CAREFULLY BEFORE SIGNING. THIS IS A LEGALLY BINDING DOCUMENT. THIS FULLY SIGNED FORM MUST BE SUBMITTED BEFORE ANY PERSON IS ALLOWED TO PARTICIPATE IN AUBURN UNIVERSITY CLUB SPORTS. I, the undersigned, wish to participate in Auburn University Club Sports (hereafter AUCS ) as indicated above and, in consideration of the mutual covenants and conditions contained in this Assumption of Risks, Informed Consent, Waiver and Hold Harmless Agreement (hereafter Agreement ), I hereby agree as follows: 1. Assumption of Risks I acknowledge, understand and appreciate that as part of my participation in Auburn University Club Sports ( AUCS ) there are dangers, hazards and inherent risks to which I may be exposed, including the risk of serious physical injury, temporary or permanent disability, and death, as well as economic and property loss. The dangers, hazards and risks may arise from my own actions, inactions, or negligence as well as from the actions, inactions or negligence of others, or the condition of the premises. I also acknowledge and understand that there may be other dangers, hazards or risks not presently known or reasonably foreseeable. Some of the risks that may be present or occur include, but are not limited to: Various injuries such as concussion, neck/spinal trauma, paralysis, broken bones, loss of teeth, or other injury as a result of body or object contact. Various injuries such as muscle pulls, cramps, sprains, strains, cuts, bruises or other injuries that can occur while training, preparing or participating in competition. Death or various injuries as a result of a traffic accident when traveling for a club activity. Death or various injuries as a result of weather conditions - i.e., lightning, hail, wind. Death or various injuries that occur during water related activities such as drowning, contact with swimmers or objects in the water, slipping or falling on deck or pool surfaces and failure to wear proper safety gear such as a life vest. Death due to cardiovascular complication as a result of physical over-exertion. Dehydration or heat stroke. Loss of vision as a result of being struck with equipment or not wearing proper protective eyewear. The list is not intended to be all-inclusive: exclusion of a hazard or risk does not negate its possibility.

2 I am aware that AUCS activities may involve strenuous exertion of strength using various muscle groups, athletic movements and change of direction, and sustained physical activity which places stress on the musculoskeletal and cardiovascular system. I acknowledge that specialized experience and skills may be necessary to participate in AUCS and confirm I possess such experience and skills. I understand that physical exercise is required for AUCS. I acknowledge that I am currently not suffering from, nor have I previously suffered from, any physical, medical and/or mental disability which would preclude me from participation in AUCS, or that would endanger me or interfere with my ability to safely participate. I acknowledge and agree that it is my responsibility to determine whether I am sufficiently fit and healthy enough to safely participate in AUCS, and I attest and certify that I am sufficiently fit and physically trained. I understand and agree that I will follow all safety precautions required for participation in AUCS. Therefore, I voluntarily accept and assume all risk of injury, loss of life or damage to property arising out of training, preparing, participating and traveling to or from AUCS. 2. Waiver of Claims In consideration of permission to voluntarily participate AUCS and use the property, facilities, and services of Auburn University, I, on behalf of myself, my heirs, personal representatives, executors, administrators, successors, assigns, and any and all other persons, firms, employers, corporations, associations, or partnerships, do hereby release, waive, and discharge Auburn University, its Board of Trustees, Administration, Faculty, Staff, Student Leaders, and all other officers, directors, employees and agents (hereafter Auburn ) from liability from any and all claims including, but not limited to, any claim for damages, relief or compensation which I may have by reason of injury, death, property damage or loss of any kind arising out of my participation in any part of AUCS. This agreement applies to: (i) personal injury (including death) from incidents or illnesses arising from participation in AUCS (including but not limited to, organized training activities, fitness tests, competitions or tournaments, observation, use of facilities or equipment, shower/locker room area, and travel to and from program related activities); and (ii) any and all claims resulting from the damage to, loss of, or theft of property. 3. Hold Harmless On behalf of myself and personal representatives, heirs, executors, administrators, successors, assigns and any and all other persons, firms, employers, corporations, associations, or partnerships, I agree to exempt, absolve, hold harmless and indemnify Auburn of and from any and all current or future responsibility, liability, duty of care, and/or claims arising out of any injury, death or loss while participating in any part of AUCS (including travel, practice or competition, being coached, triaged by trainers, using or operating equipment or otherwise participating in AUCS activities) even if such loss, damage, injury, or death is the result of negligence on the part of Auburn, or from any other cause. I hereby expressly agree to indemnify and hold harmless Auburn from any claims, losses, costs or expenses of any kind, which Auburn may incur as a result of any lawsuit, claim or demand made by myself against Auburn for any of the activities contemplated herein. 4. Covenant Not To Sue On behalf of myself and my personal representatives, heirs, executors, administrators, successors, assigns and any and all other persons, firms, employers, corporations, associations, or partnerships, I covenant not to sue and agree to never initiate, or be a party to any lawsuit, claim, demand, prosecution or action of law for any damages, relief, or compensation, which I may have by reason of injury, death, damage or loss of any kind whatsoever relating to the negligence on the part of Auburn arising out of my participation in any part of AUCS. 5. Authorization for Medical Care In the event of an accident or serious illness, I hereby authorize representatives of Auburn to obtain medical treatment for me and on my behalf. I hereby hold harmless and agree to indemnify Auburn from any claims, causes of action, damages and/or liabilities, arising out of or resulting from said medical treatment. I further agree to accept full responsibility for any and all expenses, including medical expenses that may derive from any injuries that may occur during my participation in AUCS. 6. Choice of Law This Agreement shall be governed by and construed under the laws of Alabama. I agree that any legal action or proceeding relating to this Agreement, or arising out of any injury, death, damage or loss as a result of my participation in any part of AUCS, shall be brought only in Lee County, Alabama. This Agreement contains the entire agreement between the parties to this agreement and the terms of this Agreement are contractual and not a mere recital. The information I have provided is disclosed accurately and truthfully. I have been given ample to read this document and I understand and agree to all of its terms and conditions. I understand that I am giving up substantial rights (including my right to sue), and acknowledge that I am signing this document freely and voluntarily, and intend by my signature to provide a complete and unconditional release of all liability to the greatest extent allowed by law. My signature on this document is intended to bind not only myself but also my successors, heirs, representatives, administrators, and assigns. SIGNATURE IS REQUIRED: Participant s Name Participant s Signature Parent/Legal Guardian s Name Parent/Legal Guardian s Signature A PARENT OR GUARDIAN MUST SIGN THIS FORM FOR A MINOR UNDER THE AGE OF 19

3 Auburn University Club Sports Medical Insurance Agreement Auburn University s General Liability Insurance Policy for Club Sports requires ALL members of an Auburn University Chartered Club Sport to be insured with a supplementary medical insurance policy. Each member MUST have this coverage. The coverage will be effective through August 14, The premium will not be prorated for individuals who join the club after August 15, 2016 or leave a club during the year. This is a Medical Insurance Policy that provides a maximum limit of $25,000 for Medical Expenses directly related to injuries or illnesses incurred while participating in scheduled Club Sports events. Benefits would be payable for covered claims on an excess basis after all other applicable insurance has paid. Everyone must have primary medical insurance coverage. I, the undersigned, understand I will be billed $85.00 through my Student Account for the insurance. Once this agreement has been signed there will be NO REFUND. Be advised - All billings are generated through E-Billing. Signature of Participant Printed Name of Participant AU ID Number Parent or Guardian Signature Name of Club Sport

4 AUBURN UNIVERSITY CLUB SPORTS CODE OF CONDUCT It is a privilege and not a right to be a member of a club sport at Auburn University. Every club sport athlete is expected to conduct him/herself in a manner that reflects positively on the club and Auburn University. As a member of the student body at Auburn University, each club sport athlete must act in accordance with all university policies and procedures as published by the university. In addition, club sport athletes are required to obey the requirements and prohibitions set forth by municipal ordinances and state and federal laws, both criminal and civil. To enjoy the privileges of athletics participation, I will adhere to all codes of not limited to but including those listed below: ALCOHOL & DRUG POLICY I understand that I may not consume or be in possession of alcohol or illegal drugs while serving as a member of a Club Sport and of Auburn University. This includes but is not limited to: Both on and off campus activities During travel from the time the club leaves Auburn University to the time the club returns Any activity, gathering, or social function that could be considered a club function due to the makeup of the participants Failure to adhere to this policy will result in the loss of eligibility and /or campus recognition. CONDUCT POLICY I understand that all clubs are responsible for their club members conduct during practice, games, travel, and any place or time that the club has congregated or is visible in public. Clubs have a responsibility for the conduct of their fans. Personal conduct of the club members includes but is not limited to: Appropriate dress when representing Auburn University. o Do not wear apparel with Alcohol advertisement or offensive language Use of profanity is not acceptable Vandalism and/or theft of any kind in hotels, restaurants, competition sites or any other place is not acceptable behavior Unsportsmanlike conduct of any kind at practice and/or competitions is not acceptable behavior Always present yourself in a positive image, do not say or do anything to embarrass yourself, your club or Auburn University HAZING POLICY No individual student or student organization may engage in or plan any activity that may be defined as hazing. Auburn University s definition of hazing is any action taken or situation created intentionally or unintentionally whether on or off campus, to produce mental or physical discomfort, embarrassment, harassment, or ridicule or other activities which are not consistent with organizational laws, ritual or policy or the regulations and policies of the educational institution. Actions forced or required or implied to be required, which violate federal, state, or local law, are considered hazing. Examples of hazing include, but are not limited to: Team ignitions that humiliate rookies Requiring rookies to carry the equipment to practice Performing person servitudes (favors) for upperclassmen Quest, treasure hunts, scavenger hunts that require, expect or lead to the theft or destruction of property Nudity at any time Drinking alcohol or any other substance NON-DISCRIMINATION POLICY I hereby agree that the members of this organization are free to choose and accept new members without discrimination as to race, religion, national origin, or sexual orientation. I have read and fully understand this agreement. By signing below, I agree to the policies stated above and understand that failure to fulfill these obligations can result in the loss of eligibility for participation in Auburn University Club Sports and can lead to the club being suspended from all activities. Printed Name Name of Club Signature Parent or Guardian Signature July 2014

5 CLUB SPORTS EMERGENCY CONTACT INFORMATION MUST PRINT CLUB: PHONE NUMBER: AUBURN ADDRESS: AU ADDRESS: LOCAL EMERGENCY CONTACT: PHONE NUMBER: PARENT/GUARDIAN INFORMATION: PHONE NUMBER: (H) (C) (W) ADDRESS: PHONE NUMBER: (H) (C) (W) ADDRESS: The information provided will only be used with the club member s permission. If the club member is unable to give permission (non-coherent or unconscious), then consent will be implied. July 2012