1. health and fitness

Washington University Registration Form & Liability Waiver
S40 SUMMER FITNESS CLASSES
Summer 2015
Name ___________________________________________
First
Last
WU ID # ______________________
Status (circle): Undergraduate: Fr – So – Jr - Sr - 2015 Graduate
Graduate Student
E-mail Address: __________________________________________________
Faculty
Staff
Phone #: ________________________________
HOW TO REGISTER:
Visit the S40 Fitness Center and pay by check or charge to Campus Card (Bear Bucks)
A) Fill out form, sign below agreeing to charge to Campus Card (Bear Bucks), return it by campus mail to Kristin Obert Box 1250, or
scan as PDF and email to [email protected], or fax to 935-4001
(B) Fill out form, enclose a $100.00 check (payable to WU), return it by campus mail to: Kristin Obert, Box 1250
$10/ per class if not purchasing the summer fitness class pass
IMPORTANT: PLEASE READ AND SIGN THE FOLLOWING
Statement of Personal Responsibility and Release
I understand that my class registration carries with it the responsibility of appropriate conduct and that violation of policies and
procedures as stated on the class flyer and or other abusive or irresponsible behavior may result in termination of class privileges. I also
understand that there is no partial or full refund beginning on the first day of class, May 26 and after. Class policies and procedures may be
amended at the discretion of Residential Life or Fitness Center staff.
My participation in S40 Summer Fitness Classes (collectively “Activity”) is voluntary. I understand that participation in the Activity may
be physically demanding and involve strenuous physical activity, including but not limited to muscle strength and endurance training, aerobic
exercise, cardiovascular conditioning and training, and other various fitness activities, which may severely impact the cardiovascular, muscular and joint systems. I understand that there are serious risks of injury or property damage or loss, including but not limited to minor
scrapes, pulled muscles, strains, sprains, joint injuries, bruises, broken bones, eye injury or loss, concussions, paralysis, and even death,
that may be caused by my physical condition, accidents and other factors that result from my participation in the Activity. I assume full and
complete
responsibility for any injury, personal property damage, or loss which may occur while I travel to or from the Activity or while on
the University premises engaging in the Activity. I understand that my participation in this event is potentially hazardous, and that I should
not participate unless I am medically able. I further understand that the University, including the individuals acting on its behalf, cannot and does
not assume responsibility for such Activity or personal injuries or property damage arising therefrom, even if such injury or damage is a result of
the negligence of the University or other parties released.
With full awareness of the dangers, hazards and risks of the Activity, and in consideration of being permitted to participate,
on behalf of myself, my family, heirs, and personal representatives, I agree to assume all the risks and responsibilities surrounding my
participation in the Activity and, in advance, release, waive, forever discharge, and covenant not to sue the University, or its governing
boards, officers, agents, employees, students, and/or volunteers (collectively, the “Releasees”) for any harm, damage, claim, demand,
action, cause of action, cost or expense of any nature that I may have or that may hereafter accrue to me, arising out of or related to
any loss, damage or injury, including but not limited to physical injury, suffering or death, that may be sustained by me or by any
property belonging to me, whether caused by the negligence or carelessness of the Releasees in connection with the Activity. It is my
express intent to release, waive, discharge and covenant not to sue the University or any individual acting on its behalf. I further agree
to save and hold harmless, indemnify, and defend the University and individuals acting on its behalf from any claim by me or my family
arising out of my participation in this Activity.
I warrant that I am at least eighteen (18) years of age and fully competent to sign this Release; that I understand the terms contained
herein are contractual and not a mere recital; that I have read this Release with full knowledge of its significance; and that I have signed this Release as my own free act.
Print Name_____________________________
Signature______________________________ Date_______________
CHARGING TO CAMPUS CARD (BEAR BUCKS): By signing below you indicate you are a Washington University affiliated student,
staff or faculty member, with an active account, money to cover the charge, and agree to charge the $100 class fee to said account:
Signature________________________________________ Date_______________
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FOR STAFF USE ONLY:
Receipt #________________ Paid: $__________
(Bear Bucks)
Rec’d By: ___________________________________________ Date: __________________
(Ck # __________)