Fillable Printable Sport Club Member Agreement Form

Sport Club Member Agreement Form

FR, SO, JR, SR or GRAD

SPORT CLUB

Member Agreement Form

PLEASE PRINT CLEARLY IN BLUE OR BLACK INK

I, _______________________, desire to voluntarily participate in the LSU University Recreation _________________________

Sport Club Program.

I understand that:

 Coaching instruction is normally handled by non-paid personnel;

 Often these coaches are sport club members;



It is strongly recommended that before participating in any Sport Club activity that a physical examination by a medical doctor and/or a

consultation with a health care provider be done to determine that I am physically and mentally fit and able to participate in strenuous

activities;

 Club participants have access to the student health center ONLY if they are students;

 Club participants are not covered under the Department of University Recreation or the University’s health insurance policies;

 Surgeries and other medical complications resulting from sport club participation will not be covered by the Student Health Center and will be the

individuals personal financial responsibility; and

 Club participants will be required to travel to events in privately owned and operated vehicles.

I understand and agree that there is a risk of serious injury to me while utilizing University Recreation facilities, equipment, and programs and recognize every activity has a

certain degree of risk, some more than others. By participating, I knowingly and voluntarily assume any and all risk of injuries, regardless of severity, which from time to time

may occur as a result of my participation in athletic and other activities through LSU University Recreation.

I hereby certify I have adequate health insurance to cover any injury or damages that I may suffer while participating, or alternatively, agree to bear all costs associated with

any such injury or damage myself.

I further certify that I am in good health and have no mental or physical condition or symptoms that could interfere with my safety or the safety of others while participating in

any activity using any equipment or facilities of LSU University Recreation. I understand and agree that I alone am responsible to determine whether I am physically and

mentally fit to participate, perform, or utilize the activities, programs, equipment or facilities available at Louisiana State University, and that I am not relying on any advice

from LSU University Recreation in this regard. To the extent I have any questions or need any information about my physical or mental condition or limitations, I agree to

seek professional advice from a qualified physician.

Further, I hereby RELEASE AND HOLD HARMLESS, the State of Louisiana, the Board of Supervisors of Louisiana State University and Agricultural & Mechanical College,

and its respective members, officers, employees, student workers, student interns, volunteers, agents, representatives, institutions, and/or departments from any and all

liability, claims, damages, costs, expenses, personal injuries, illnesses, death or loss of personal property resulting, in whole or in part, from my participation in, or use of, any

facility, equipment, and/or programs of Louisiana State University. In case of an emergency, this consent also authorizes the release of this form and all medical and acci-

dent report forms to emergency personal, doctors, hospitals, insurance companies, my employers, other person or entities deemed appropriate by Louisiana State University.

Photography is permitted in LSU UREC facilities for personal non-commercial and lawful use provided permission has been granted by the individual(s) being photo-

graphed. The taking, capturing or recording of any and all photography, audio, or video of any kind in the pool, men’s and women’s locker rooms, and restrooms is strictly

prohibited. Those who seek to photograph, film, or interview individuals at LSU UREC facilities for commercial use, media use, or class projects, must receive prior written

approval from University Recreation administration prior to accessing LSU UREC facilities.

By entering a LSU UREC facility, you consent to being the subject of any photography, audio, or video recordings, which may take place while you are participating in pro-

gramming and/or open recreation activities. Such photography and recordings may be used for LSU publications, webcasts, telecasts, advertising, and for any other addition-

al promotional or marketing purpose as Louisiana State University may see fit. By entering a LSU UREC facility, you hereby waive all rights or claims you may have to any

financial compensation or payment of royalties in connection with any publications, webcasts, broadcasts, or exhibition of these materials. When/if your likeness or image is

used in a publication, there will be no identifying information provided. If you do not wish to be photographed, please kindly inform our photographer or videographer.

I HAVE READ THIS AGREEMENT AND UNDERSTAND ALL ITS TERMS.

____________________________ ___________________________________

Signature, Club Member Date

____________________________

Printed Name, Club Member

Revised 8/8/2012

Member Name: Sport Club:

Date of Birth: ID#: Classification:

Semesters in Club: Male/Female:

Local Phone: Email Address:

Emergency Contact Name: Emergency Phone: