Fillable 2018 FacultyStaff SPOUSE LaHaye Membership Form LaHaye Membership Registration

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2018 FacultyStaff SPOUSE LaHaye Membership Form LaHaye Membership Registration

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Spouse Membership
Registration Form
Activation Date: __________ New Member ____
Expiration Date: __________
Member Information (spouse):
Name: ___________________________________________________________________
Department: _________________ Work Phone #: _____________________________
Address: _________________________________________________________________
City: ______________________ State: __________ Zip: ________________________
Home Phone: __________________ Email: __________________________________
Relation to Member: _________________
Work Phone: _______________________
Emergency Contact:
Name: _____________________________
Home Phone: _______________________
Summer Spouse Options:
Week $15 ____
Month $30 ____
Summer $75 ____ (6/4/2018-8/21/2018)
I agree to abide by all LaHaye Recreation & Fitness policies and procedures and The Liberty Way. I know 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 also agree that falsifying any information on this form will result in a loss of membership privileges without refund. I understand
refunds will not be issued for closure dates due to university closures, holidays, facility maintenance, etc. which will occur throughout
the year. I understand membership fees will not be refunded in the event of employee resignation or termination from the University.
_____________________
Membe
r Signature
________________________
Date
For Office Use Only:
Manager’s Initials: Today’s Date:
Payment:
Cash Amount Due Amount Paid Date Paid
Check
CC
Payment Received by: (PRINT) Signature
Liberty Faculty/Staff Information
Name: ___________________________________________________________________
LU ID#: ____________________
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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
____________________________________________________ ___________________________________________________________________
Participant Signature Date: (mm/dd/yyyy)
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2018 FacultyStaff SPOUSE LaHaye Membership Form LaHaye Membership Registration

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Completed 16 February 2020

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