Dodge Physical Fitness Center Mail Code 1923 3030 Broadway New York, NY 10027 Phone (212) 854-4002 Fax (212) 854-7397 www.gocolumbialions.com

WAIVER OF LIABILITY

As a condition of my participation in Club Sports at Columbia University, and my use of the University's facilities in connection therewith, I agree and acknowledge that neither the Trustees of Columbia University in the City of New York, nor its trustees, officers, agents or employees (the "University"), shall have any liability to me or to my heirs or legal representatives as a result of any loss, injury or damage (including death) incurred or suffered by me in connection with such participation and use and I hereby expressly waive all rights, claims, causes of action and the like, of any nature whatsoever, which I or my heirs or legal representatives may have against the University in connection with my participation in Club Sports at Columbia University and my use of the University's facilities in connection therewith.

2011-2012 Season Club Sport

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UNI

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CUID Number (9-digit number on top right corner on back of CUID)

Local / School Address

Cell Phone

Permanent Address

Home Phone

COLUMBIA – BARNARD ATHLETIC CONSORTIUM

waiver of liability - Columbia University

Cell Phone. Permanent Address. Home Phone. Dodge Physical Fitness Center. Mail Code 1923. 3030 Broadway. New York, NY 10027. Phone (212) 854-4002.

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