Fill - Free fillable 2018 Alumni Membership Registration INCIDENT REPORT PDF form

Alumni Membership Registration

Attach Copy:

Activation Date: __________ Proof of Graduation

Expiration Date: __________ Government Issued ID

Member Information:

Name: ________________________________________

Address: _______________________________________________________________

City: ______________________ State: ___________ Zip: ______________

Home Phone: __________________ Email: __________________________________

Emergency Contact:

Name: ____________________________Relation to Member: _________________

Cell Phone: _______________________ Work Phone: _______________________

Membership Package:

____ Week $15

___

__ Month $45

_____ Summer $120

(6/4/2018–8/21/2018)

I agree to abide by the policies and procedures of 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 summer LaHaye Recreation & Fitness

Center may be closed due to university closures, holidays, facility maintenance, camps, 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. Alumni members will be required to show proof of graduation when purchasing tier and weekly packages. Alumni

members are required to show government issued ID and membership card each time when entering the facility. All Alumni

membership will end effective 8/22/2017.

_______________________________ ________________________

Member Signature Date

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

Amount Due: Amount Paid: Date Paid:

Payment Received by [Print] Signature

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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 LaHaye Recreation & Fitness (“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 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 LaHaye Recreation & Fitness 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.

Express members have access from open – 3:00 pm Monday through Saturday. Early Bird

members have access from open – 3:00 pm Monday – Friday and all day Saturday and

Sunday. Early Bird Plus members have access during all operational hours.

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-

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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

____________________________________________________ ___________________________________________________________________

Fill Online, Printable, Fillable, Blank 2018 Alumni Membership Registration INCIDENT REPORT Form

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Fillable 2018 Alumni Membership Registration INCIDENT REPORT

Fill Online, Printable, Fillable, Blank 2018 Alumni Membership Registration INCIDENT REPORT Form

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