Club Sports Registration/Insurance/Liability Waiver In consideration for my being permitted to participate in the Club Sports program, I, the undersigned, in recognition and appreciation of the dangers and hazards inherent in the foregoing recreational sports activity hereby assume the risk and responsibility for my participation in the foregoing activity and in other activities undertaken as an adjunct thereto; and further, I, for myself, my heirs, and personal representative(s) hereby defend, hold harmless, indemnify, release, and forever discharge the Metropolitan State University of Denver and the Club Sports program and all its trustees, officers, and actions or causes of actions on account of damage to personal property or personal injury or causes beyond control and without gross negligence of Metropolitan State University of Denver and the Club Sports Program, its trustees, officers, agents, or employees, during the period of my participation as aforesaid. I also agree to not sue Metropolitan State University of Denver, the Club Sports Program, or any club officers or agents. In consideration of permission to use my own car and be eligible for a travel reimbursement, I hereby agree to the following: I certify that sufficient insurance is currently in force on my vehicle which will protect my passenger(s), if any, and myself, and that this insurance complies with the minimal provisions prescribed by the Colorado Auto Accident Reparations Act (No Fault Coverage) or the insurance laws of the state in which my car is licensed. I understand that any financial loss shall not be reimbursed by Metropolitan State University of Denver, the Campus Recreation Program, the Club Sports Program, nor by the passengers I permit to share in the driving. I understand that any illegal activity I or my passengers engage in resulting in any financial loss shall not be reimbursed by the University, and the University assumes no responsibility for my actions or conduct. In the event that an accident occurs while on a university related trip, I agree to report the details to the Club Sports Director within 48 hours. I also agree to release the Club Sports Program to access my academic information, including my grade point average (GPA) and current academic status. If I do not completely fill out all information or sign this waiver, I recognize that I am not a member of any club sport and cannot participate with any club sport.
Signature: ____________________________________ Date: ____/____/______ If under 18 years of age, parent/guardian must sign: ________________________
All Information Is Required (please print clearly) Club Sport: ___________________________________
Male
Female
Name: ____________________________________ Age: ______ Current Address: _______________________________________________________________ City: _____________________ State: _____ Zip Code: __________ Phone: (
) _____ - _______ Email Address: _________________________________
Permanent Address: _____________________________________________________________ City: _____________________ State: _____ Zip Code: __________ Phone: (
) _____ - _______
School Affiliation:
MSUD
UCD
CCD
ID#: _______________________
Health Insurance Company: _______________________________________________________ Policy #: ________________________________ Expiration Date: ____/____/_______ Allergies:
Y
N
Medical Conditions: Y
If yes, to what? ____________________________________ N
If yes, please list: _______________________________
________________________________________________________________________
Auto Insurance Company (optional): _______________________________________________ Policy #: ________________________________ Expiration Date: ____/____/_______
Emergency Contact: Name: __________________________________________________________________ Address: ________________________________________________________________ City: _______________________ State: ________ Zip Code: ___________________ Cell Phone: (
) _____ - ________ Other Phone: (
) _____ - ________
Relationship to you: _______________________________________________________