Community Programs Registration Form for Danzi Athletic Center, SJC

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Information about Community Programs Registration Form for Danzi Athletic Center, SJC

Published on March 1, 2014

Author: kkaufer



Community Programs Registration Form

CONSENT FORM FOR COMMUNITY PROGRAMS At St. Joseph’s College John A. Danzi Athletic Center We request your understanding and cooperation maintaining both your safety and ours, by reading and signing the following informed consent agreement. I, ____________________________________________, declare that I intend to use some or all equipment available in the St. Joseph’s College Athletic Center and understand that each person, myself included, has different capacity for participating in such activities. I assume full responsibility, during and after my participation, or my choices to use or apply, at my own risk, a portion of the information and instruction I receive. I understand that part of the risk involved in understanding any activity or program is relative to my own state of fitness or health (physical, mental or emotional) and to the awareness, care and skills with which I conduct myself in that activity or program. I acknowledge that my choice to participate in any activity, service, and program of the St. Joseph’s Athletic Center brings with fitness, health, awareness, care and skill I possess and use. I further understand that the activities, programs and service offered by St. Joseph’s College Athletic Center are sometimes conducted by personnel who may not be licensed, certified, or registered instructors or professionals. I accept the fact that the skills and competencies of some employees and/or volunteers will vary according to their training and experience and that no claim is made to offer assessment or treatment of any mental or physical disease or condition by those who are not duly licensed, certified or registered and herein employed to provide such professional services. In consideration of my participation in this exercise program, _____________________________, for myself, my heirs and assigns, hereby release St. Joseph’s College (it employees and owners), from any claims, demands and causes of action arising from my participation in the exercise program. I recognize that by participating in the activities, facilities, programs, and services offered by the Athletic Center, I may experience potential health risks such as light headedness, fainting, abnormal blood pressure, chest discomfort, leg cramps, and nausea and I assume willfully those risks. I acknowledge my obligation to immediately inform the nearest supervising staff member of any pain, discomfort, fatigue, or any other symptoms that I may suffer during and immediately following my participation. I understand that I may stop or delay my participation in any activity or procedure if I so desire, and I may also be requested to stop and rest by a supervising employee who observes any symptoms or distress or abnormal response. I understand that I may ask questions or request further information about the activities, facilities, programs, and services offered by St. Joseph’s Athletic Center at any time before, during or after my participation. I declare that I have read, understand, and agree to accept full responsibility for any accident, injury, or death that may occur due to my use of the Athletic Center. SIGNATURE____________________________________________________DATE_____________________________ REGISTRATION FOR COMMUNITY PROGRAM Course Title____________________________________ Cost__________ Day/Time____________________________ Name _____________________________________________________SJC Student ____ Employee ____ Other _____ Address _________________________________ Town__________________________State_____Zip ______________ E-Mail Address ____________________________________________________________________________________ Phone# _____________________________ Emergency Contact Name & # ____________________________________ A separate registration is required for each class Staff Use Only! PD___________ Method______ Completed form must be returned with payment to: St. Joseph’s College, Danzi Athletic Center, Att: Kimberly Teague 155 W. Roe Blvd., Patchogue, NY 11772 If registering in person please go to the Danzi Athletic Center Make check payable to St. Joseph's College Completed registration must be returned with payment in order to secure a place in the class. No refunds will be made after the class begins 2/7/14 kt Amount_____

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