Campus Recreation : Membership

SRC Membership Form

Contact Information

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Affiliation:

First Name:

Last Name:

Preferred Name (optional):

WCU Email:

Email:

Phone:

- Phone (next 3 digits): - Phone (last 4 digits):

Department:

Employee ID:

Emergency Contact First Name:

Emergency Contact Last Name:

Emergency Phone:

- Emergency Phone (next 3 digits): - Emergency Phone (last 4 digits):

Guest Information

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Guest First Name:

Guest Last Name:

Guest Email:

Guest Phone:

- Guest Phone (next 3 digits): - Guest Phone (last 4 digits):

Guest Emergency Contact First Name:

Guest Emergency Contact Last Name:

Guest Emergency Phone:

- Guest Emergency Phone (next 3 digits): - Guest Emergency Phone (last 4 digits):

Membership Information

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Membership:

Employee Type:

9 month 12 month

Informed Consent Statement

I am aware of my physical condition.
I am aware that such participation may result in possible injury as a result of the nature of the activity and that I am assuming any risk that may be involved in the activity.

I understand that part of the risk involved in undertaking any recreational activity is relative to my own state of fitness or health (physical, mental, or emotional) and to the awareness, care, and skill with which I conduct myself in that activity. I acknowledge that my choice to participate in the Student Recreation Center brings with it my assumption of those risks or results stemming from this choice and the fitness, health, awareness, care and skill that I possess and use.

I understand that student personnel working in the Student Recreation Center may not be licensed, certified, or registered professionals. I accept the fact that the skills and competencies of some employees and/or volunteers will vary according to their training and experience. I understand that the dangers and risks from my participation in the Student Recreation Center may include injury to virtually all internal organs and other aspects of the muscular/skeletal system, to other aspects of my body, and general health and well being, including serious injury which may result in loss of life. I acknowledge that I am responsible for my injuries I may sustain, that I may cause to others, and damage I may cause to the facilities.

I agree to indemnify and hold harmless the University, Student Services, Inc., PASSHE, the State System of Higher Education, its Trustees, officers, agents and employees of the Student Recreation Center, from and against any and all claims, liability, losses, third party claims, damages, costs, or expenses (including attorneys’ fees), from any responsibility or liability in case of personal injury sustained by me or damage to property of others caused by me during or because of participation in the activities of the Student Recreation Center.

I certify that I am a legally competent adult 18 years of age or older

My signature verifies that I have read, understood, and agree to the contents of this Informed Consent Statement in its entirety. I have the opportunity to ask any questions related to this Informed Consent Statement.

Signature:

I Agree to Terms

Total: $0.00