Fill - Free fillable 2018 All Access Membership-Registration PDF form

All Access Membership

(LaHaye, David's Place, Bowling Alley)

Activation Date: Attach copy of Government Issued ID _____

Expiration Date: *Proof of Graduation _____

Member Information: Member Type Eligibility:

Name: ___________________________ Faculty/Staff _____

LU ID#: LUO/Grad _____

Address: ______________________________________________________ Alumni* _____

City: _______________________ State: _______________ Zip: __________ Spouse _____

Home Phone: ___________________ Cell Phone: ___________________ Spouse ID# ___________________

Email: ____________________________

Emergency Contact:

Name: ___________________________ Relation to Member: _____________________________

Home Phone: Work Phone: Cell Phone:

Swim Pass Family Members: SPOUSE: _________________________

1. Age: _____ 2. _____________ ____________Age: _____

3. Age: _____ 4. Age: _____

Payment:

_____ Cash

_____ Check

_____ CC

Pricing:

_____ $175 Month

_____ $375 All Summer

Membership Package:

_____ Month (30 days from start date)

_____ All Summer (6/4/2018 – 8/21/2018)

I agree to abide by the policies and procedures of the LaHaye Recreation & Fitness Center and the Liberty Way. I know that I have access to the

policies and procedures of the Rec Centers upon request. I also agree that falsifying any information on this form will result in a loss of membership

privileges without refund. I understand that throughout the year the Rec Center may be closed due to university closures, holidays, facility

maintenance, etc. Memberships will not be refunded or reimbursed in any way for these closure dates. Closures will be posted at the Rec Centers

front desk as well as on the university splash page.

______________________________________ ____________________________

Member Signature Date

For Office Use Only: Manager’s Initials: _______ Today’s Date:_________________

Amount Due: __________________ Amount Paid: ________________ Date Paid: _____________

Payment Received by: (PRINT) Signature

*Families with more than 4 children purchasing a Month or Summer pass will be required to pay $10 for each additional child.

Participation Agreement

**Please consult a physician prior to any form of physical activity**

Before I may participate in any exercise and/or fitness related event/activity

(“Activity”) within or sponsored by the LaHaye Recreation & Fitness Center (“LaHaye”), I

understand that I must read and promise to be bound by the following terms.

General Terms.

I hereby agree to abide by all LaHaye Recreation & Fitness Center policies and procedures

and The Liberty Way. I am aware that I have access to the policies and procedures upon

request. I agree to notify the LaHaye Recreation & Fitness Center staff of any potential

health changes or concerns. I understand that falsifying any information on this form will

result in a loss of membership privileges without refund. I understand that refunds

will not be issued for closure dates due to university closures, holidays, facility

maintenance, etc., which will occur throughout the year. I further understand that

membership fees will not be refunded in the event of employee resignation or

termination from the University.

LUO*/Grad students must be currently enrolled in classes and be financially check-

in throughout the duration of their membership. * Must currently be enrolled in B exit

term classes to be eligible.

Assumption of Risks.

I AM AWARE THAT ACTIVITIES AT LAHAYE, WHETHER OR NOT REQUIRING THE USE

OF EXERCISE EQUPMENT, CAN BE DANGEROUS. I AM AWARE THAT PLAYING OR

PARTICIPATING IN ANY ACTIVITY AT LAHAYE HAS CERTAIN INHERENT RISKS WHICH

MAY AFFECT ME, INCLUDING, BUT NOT LIMITED TO, PROPERTY DAMAGE OR LOSS,

TEMPORARY OR PERMANENT BODILY INJURY, SICKNESS, DISEASE, AND EVEN DEATH.

Specific risks that may be involved in this Activity include, but are not limited to:

unwanted contact with other players or participants and their equipment, equipment

failure, fast-moving equipment (including things like balls), contact with the playing

surface and surrounding elements, slipping, tripping, falling, and my individual

susceptibility to harm or injury (whether known or unknown to me). The results of these

and other inherent risks may include, but are not limited to: serious neck and spinal

injuries which may result in complete or partial paralysis and/or brain damage; serious

injury of the musculoskeletal system, serious injury or impairment to other aspects of my

body, general health, and well-

being, and even death. I understand that the dangers and risk of playing or participating in

this Activity may result in not only serious injury, but also in serious impairment to my future

abilities to earn a living, engage in other business, social and recreational activities, and

generally to enjoy life. I am voluntarily playing or participating in this Activity will full

knowledge, understanding, and appreciation of the risks involved, and hereby agree to

assume any and all risks associated with the Activity.

Medical Treatment Authorization.

I agree that I am in sufficiently good health to play or participate in the Activity and that I am

free from any medical condition, physical or mental, that could interfere with my ability to

play or participate in the Activity or that could be worsened by playing or participating in

the Activity or that could endanger my health or safety or the health or safety of other

participants. If I require emergency medical treatment as a result of accident or illness

arising during the Activity, I consent to such treatment.

Medical Examination; Medical Fitness.

I am aware that an examination by a physician should be obtained prior to commencing a

fitness and/or exercise program, or initiating a substantial change in the amount of regular

physical activity performed. Should I choose not to be examined by a physician, I hereby

agree that I am doing so solely at my own risk and expense.

Governing Law; Forum Selection.

This agreement will be governed by and construed in accordance with the laws of the

Commonwealth of Virginia. Any controversy, dispute or claim arising out of or relating to

this agreement must be brought in a court located in Lynchburg, Virginia. Each party submits

to the jurisdiction of such courts.

BY SIGNING BELOW, I AGREE I HAVE CAREFULLY READ AND UNDERSTAND THIS

AGREEMENT. I AGREE TO ALL OF THE TERMS ABOVE, AND HEREBY ASSUME THE

RISKS ASSOCIATED WITH MY PARTICIPATING IN ACTIVITIES AT LaHaye

Recreation & Fitness Center.

_______________________________ ________________________________

Date of Birth (dd/mm/yyyy) I.D. # (student or staff only)

__________________________________________________ ___________________________________________________________________

Participant Name (print) Participants under 18 must also have legal guardian sign

____________________________________________________ ___________________________________________________________________

Participant Signature Date: (mm/dd/yyyy)

David’s Place Summer Pool Policy:

- Eligible parties (Faculty/Staff, Alumni, Students, and Spouses) have the opportunity to purchase a Family

Summer Swim Pass for their spouse and 4 immediate family members for the summer session (6/04/2018 –

8/21/2018)** (Children 2 and under are permitted free of charge)

- Purchase can be made at the LaHaye Recreation & Fitness Center front desk and the patron must bring over a

copy of the membership form for proof of purchase to the David’s Place front desk.

- When you sign up for the Family Summer Swim Pass you must list your spouse and your 4 immediate family

members names that will be underneath your pass. *Falsification of information stated on the Membership Form may

result in immediate termination of membership.

- Each member will be given a card that you must show at the David’s Place front desk. In addition to the issued

membership card, all cardholders must show government issued ID upon entering the facility.

- Immediate family members on the card must be 18 years or older to enter the David’s Place without the

purchasing member.

- You may host swim pass members from a different swim pass, provided you take responsible for these guests

throughout the duration of your visit and sign an assumption of liability prior to entering the facility.

- Additional guests must be immediate family members, as stated in the LaHaye Recreation & Fitness Center

Policies and Procedures, and will be required to pay a daily fee of $5.

- Those who purchase a daily membership will be required to sign in at the front desk of the facility.

*If the David’s Place pool is closed by the Campus Recreation staff because of inclement weather you are allowed to use

the LaHaye Student Union pool during normally schedule David’s Place Pool hours*

** Families with more than 4 children will be required to pay for each additional child

depending on the duration of the purchase**

David’s Place Pool Rules

- Please shower off before entering the pool

- Failure to comply with the Campus Recreation Staff will result in the termination of patron’s Summer Swim pass

and membership without refund.

- All patrons must follow the “Liberty Way” dress code when entering into a Campus Recreation facility

- Swimwear is only allowed around the pool and pool deck and must follow the “Liberty Way”.

- Campus Recreation Staff will enforce dress code with all patrons. Patrons may be asked to leave until they

comply with the rules set by the “Liberty Way”.

- The Campus Recreation Staff has the authority to close the pool due to weather conditions, mechanical failures, or

over occupancy.

- Aquatic toys and flotation devices may be used however; Campus Recreation Staff may refuse use of floats or

toys at their discretion.

- No animals are allowed in the facility, pool, or on the pool deck

- No food or drink is allowed in the pool.

**For more information please contact the LaHaye Recreation & Fitness Center at (434) 592-3148

Fill Online, Printable, Fillable, Blank 2018 All Access Membership-Registration Form

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Fillable 2018 All Access Membership-Registration

Fill Online, Printable, Fillable, Blank 2018 All Access Membership-Registration Form

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