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Sports Club Waiver and Participation Packet



WAIVER AND AGREEMENT FOR PARTICIPATION IN SPORTS CLUBS PROGRAM
1. I wish to voluntarily participate in this Sports Club (herein referred to as the ACTIVITY)
2. I understand that there are risks which are inherent in the nature of the ACTIVITY including, but not limited to, serious physical injury and death.
3. I hereby consent to and voluntarily assume all risks flowing from my participation in the ACTIVITY.
4. I hereby waive any claim or cause of action against the Undergraduate Student Association of the State University of New York at Buffalo (“SA”), the sports club, the State University of New York at Buffalo (“UB”) or any of their officers, directors, agents, servants, volunteers or employees, resulting, directly or indirectly, from my participation in the Sports Clubs program and/or the ACTIVITY. I specifically waive any claim or cause of action arising from negligence by SA, the sports club, UB or any of their officers, directors, agents, servants, volunteers or employees, and hereby release and hold harmless SA, the sports club, UB and their officers, directors, agents, servants, volunteers or employees from any such claim.
5. I understand that the Undergraduate Student Association of the State University of New York at Buffalo (“SA”) does not provide any health/medical insurance coverage to participants in the Sports Club program and will not provide health/medical insurance coverage for me should I be injured while participating in the ACTIVITY.
6. I hereby certify that I have health/medical insurance coverage and that I will maintain this coverage for the duration of my participation in the ACTIVITY.
7. I hereby consent to first aid and emergency medical care, including admission to a hospital and transportation thereto, should I sustain an injury while participating in the ACTIVITY. I shall not hold SA, any sport club or UB responsible for any costs/expenses I may incur as a result of first aid or emergency medical care.
8. I hereby certify that I am in good health and medically able to participate in the ACTIVITY.
9. I acknowledge that SA strongly recommends that I consult a physician and/or have a physical examination before participation in the ACTIVITY.
10. If at any point I shall become aware that I am medically unable to participate in the ACTIVITY, I shall immediately inform the club president or coach and remove myself from competition/practice until I am medically fit to participate.
11. During my participation in the ACTIVITY, I shall remain sober and free of the influence of alcohol, illegal drugs or any substance which could negatively impact my ability safely participate in the ACTIVITY.
12. I will follow the rules and instructions of SA, the sports club, any league/organization governing the ACTIVITY and any officials administering the ACTIVITY. I understand that failure to abide by these rules or instructions may result in my disqualification from the ACTIVITY.
13. I acknowledge that I have read this agreement in its entirety and that I fully understand and consent to its terms.
First Name:(*)
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Last Name:(*)
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Address:(*)
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Age:(*)
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Phone Number:(*)
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UB Person Number:(*)
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Activity:(*)
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Sign Here:(*)
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If participant is under the age of 18, the participant’s parent or legal guardian must sign below. By doing so, the parent or legal guardian acknowledges reading the agreement in its entirety, fully understanding its terms and consenting to all terms on behalf of the participant.
Parent/Guardian Name:
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Relationship to Participant:
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Parent/Guardian Signature:
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In Case of Emergency, You Would Like Us to Contact:
Name:(*)
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Phone Number:(*)
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Relationship to Participant:(*)
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Personal Information Form
First Name:(*)
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Last Name:(*)
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Club Name:(*)
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Local Address:(*)
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Local Phone Number:(*)
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Home Address:(*)
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Home Phone Number:(*)
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Medical Insurance Information
Name of Insurance Provider:(*)
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Policy Number:
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Medical History Questionnaire
PLEASE NOTE:
ANY APPLICANT WHO ANSWERS YES TO ANY OF THE FIRST SIX QUESTIONS WILL BE REQUIRED TO PROVIDE A LETTER FROM THEIR PHYSICIAN INDICATING CLEARANCE TO PARTICIPATE IN PHYSICAL ACTIVITY. THE APPLICANT WILL NOT BE APPROVED TO PARTICIPATE UNTIL SUCH LETTER IS RECEIVED.
Have you previously experienced dizziness or headaches during physical activity?(*)
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If yes, describe:
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Have you ever been diagnosed as having a hernia?(*)
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Have you ever been unconscious or experienced a concussion?(*)
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If yes, describe:
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Have you ever had a neck injury requring medical attention?(*)
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If yes, describe:
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Have you had any operations in the past four years?(*)
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If yes, describe:
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Are you currently under the care of a physician for an on-going condition?(*)
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If yes, describe:
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Do you have any allergies to substances or medications?
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If yes, describe:
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Have you been treated for diabetes?
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Do you wear contact lenses?
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Do you wear any dental appliances?
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If yes, describe:
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Have you ever had a wrist or hand fracture or severe injury?
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Have you ever experienced a severe sprain, dislocation, or fracture of either elbow?
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Have you ever experienced a dislocation or separation of either shoulder?
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Have you ever had knee arthroscopy or surgery?
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If yes, describe:
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Do you wear a knee brace?
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Have you experienced a severe sprain, strain, or surgery to either foot or ankle?
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Have you had an injury to your upper or lower back?
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Do you experience pain in your back?
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If yes, describe:
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Are you currently on prescribed medication?
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If yes, what medications?
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List medications:
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By signing below, I indicate that I have read and answered all questions truthfully and to the best of my knowledge.
Signature:(*)
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