June 10, 2022 Participant Information / Medical Consent & Release - Adult Participant Name* First Last Email Address* Program*SailingFitnessAquaticsPlease choose the program you are submitting this form to.Phone Number* Age*Date of Birth* Gender*MaleFemaleAddress* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Medical Insurance InformationMedical Insurance Company* Policy Number* Name of Primary Policy Holder* Emergency ContactsEmergency Contacts*NameRelationshipPhoneCell Please list anyone you would like the URI Campus Recreation staff to contact in the event of an emergency situation.NameRelationshipPhoneCell Participant's Health HistoryDo you have any of the following? Seizures Heart Defect or Disease Diabetes Bleeding / Clotting Disorder Asthma or Breathing Conditions Muscle, Bone, or Joint Problems Previous Injury Still Affecting Ever been Knocked Unconscious Frequent Ear Infections or have Ear Tubes Wear glasses or Contacts Orthodontic Appliance being brought to Lesson Physical Limitations Special Fears or Conditions Received a Physical examination in the past 12 months Please describe any Details/Limitations due to any of the above choicesExtra Details*Is there anything else we should know about? If so, please describe above, or state "NONE"The Department of Campus Recreation reserves the right in its sole discretion to decline any participants for safety reasons.Serious AllergiesAllergies*NO - The participant does NOT have any allergiesNONE - that we are aware ofYES - The participant has allergies (if yes, please list below)Does the participant have any serious allergies?Medication Allergies (Please list)AllergyDescribe reaction & management of reaction AllergyDescribe reaction & management of reaction Food Allergies (Please list)AllergyDescribe reaction & management of reaction Press the [+] on the right to add moreAllergyDescribe reaction & management of reaction Other Allergies Including Insect Stings, etc. (Please list)AllergyDescribe reaction & management of reaction Press the [+] on the right to add moreAllergyDescribe reaction & management of reaction If participant requires medication for allergic reactions, please bring one dose and the participant must present information to URI Campus Recreation approved personnel at check-in of the first day.I CERTIFY THAT THE ABOVE INFORMATION IS TRUE, CORRECT, AND COMPLETEI have read and agree to URI Campus Recreation Consent Form* By agreeing electronically, you acknowledge that you have both read and understood all text presented to you in this form.YOUR SIGNATURE INDICATES COMPLIANCE WITH URI CAMPUS RECREATION MEDICAL CONSENT AND RELEASE POLICIES AND PARTICIPANT HEALTH HISTORY* I have read and agree to the Consent Form Assumption of Risk and Release of Liability FormIn consideration of my voluntary participation in URI's Department of Campus Recreation's programs and facilities:I confirm I hereby waive, release, fully discharge and quitclaims unto The University of Rhode Island, its governing board, the Rhode Island Board of Education, the State of Rhode Island and their officers, directors, board members, employees, agents, and assignee for any and all liability and claims, or demands and/or cause of action, that I have or may have for any costs, expenses, or damages, including reasonable attorneys' fees, arising from property damages or personal bodily injury, including death, relating to or arising from my participation in, use of, or operation of equipment related to the Activities or may in the future have, whether known or unknown, arising out of the named Activity.I may or may not have had previous participation experience in the Activity. I understand and acknowledge that such participation could result in loss of or damage to my or another person's property, serious injury to my body, including mental or emotional injury or trauma and/or death. I verify that I have no physical or emotional conditions, which may prevent me from fully participating in the Activity.I understand and agree The University of Rhode Island and its recreational subsidiaries cannot be expected to control all possible risks but may need to respond to accidents and potential emergency situations. Therefore, I hereby give my consent for any medical treatment that may be required during an attendance with the understanding that cost of any such treatment will be my responsibility. The University does not carry medical or accidental insurance for the activities mentioned. As such, participants should review their personal insurance portfolio.I HAVE READ THE WAIVER, RELEASE AND ASSUMPTION OF RISK FORM IN ITS ENTIRETY AND UNDERSTAND THE TERMS AND LEGAL SIGNIFICANCE. This waiver is freely and voluntarily given with the understanding that right to legal recourse is knowingly given up in return for allowing my participation in the Activity.By signing below, I agree that I have read and understand the above information.I have read and agree to URI Campus Recreation Assumption of Risk and Release of Liability Form* By agreeing electronically, you acknowledge that you have both read and understood all text presented to you in this form.YOUR SIGNATURE INDICATES COMPLIANCE WITH URI CAMPUS RECREATION ASSUMPTION OF RISK AND RELEASE OF LIABILITY FORM* I have read and agree to the Consent Form Acknowledgement of Participation Information, Authorization And Release1. PARTICIPATION: In consideration for my voluntary participation at URI Campus Recreation, I hereby acknowledge that I am in good physical and mental health and that unless I have notified the University in writing that I am unable to aprticipate in the activity due to some physical or mental consideration, I will be allowed to participate in all aspects of URI Campus Recreation.2. PHOTOGRAPHS/VIDEOS/SOCIAL MEDIA PERMISSION: I may be photographed (stills and videos), individually or in a group. We hereby waive and relinquish all rights, title and interest in all such products, and authorize URI Campus Recreation authorized staff to make use of participant's images and likeness for marketing, membership information, and other URI Campus Recreation uses.3. BEHAVIORAL MANAGEMENT: There are three basic rules that are easy to understand and follow: BE SAFE, BE KIND, AND PARTICIPATE. We want to foster responsibility, respect, and accountability at URI Campus Recreation so our approach to discipline will reflect this goal. any discipline will be: constructive in nature, using limits that are fair, consistently applied and understandable for the student. Campus Recreation Coordinators will communicate with the student if deemed necessary. if the student continuously displays inappropriate behavior or engages in dangerous activities, the Campus Recreation Coordinator and the Department of Campus Recreation authorized personnel reserve the right to suspend any participant, at any time, without a refund.4. TRANSPORTATION: URI Campus Recreation authorized personnel are not permitted to transport participants by car (or any other type of land transportation), to and/or from, any off-site activities; and/or in an event of a medical emergency.I certify as the above named participant, I have reviewed all regulations listed in items #1-#4 above. I understand all of the terms and conditions of the above, hereby consent, and grant my permission to each and all of the foregoing.I have read and agree to URI Campus Recreation Acknowledgement of Participation Information, Authorization, and Release Form* By agreeing electronically, you acknowledge that you have both read and understood all text presented to you in this form.YOUR SIGNATURE INDICATES COMPLIANCE WITH URI CAMPUS RECREATION ACKNOWLEDGEMENT OF PARTICIPATION INFORMATION, AUTHORIZATION AND RELEASE* I have read and agree to the Consent Form Registration PolicesThis URI Campus Rec program is a tuition for service program based on confirmed enrollment and secured deposit. Full registration payments must be received prior to the first day of Activity. All mandatory forms must be received by no later than the first day of each Activty.Registration application will be accepted on a first come, first serve basis.All online registrations will have convenience fee added to the transaction. This amount is added on as a flat fee to your transaction total and goes directly to our registration service provider. The flat fee is only added one time to your total amount, even if you are paying for multiple sessions or campers at that time. If you register separately for each activty session, the convenience fee applies to each transaction. If a medical condition arises, a letter for the doctor is required and will be evaluated by the Director of Campus Recreation on any partial credit if applicable. Each class will have a limited number of participant spaces available. I understand no refunds will be made. Returned checks or charges will be assessed a $20.00 fee. Withdrawal Policy: A withdrawal fee will be assessed for all activities as follows: 25% of registration fee will be credited to client’s account. All withdrawals must be prior to the third class. No credits will be given after the third class. A 25% withdrawal fee will be assessed for all withdrawals and must notify URI Campus Recreation prior to activity. I have read and agree to URI Campus Recreation Acknowledgement of Participation Information, Authorization, and Release Form* By agreeing electronically, you acknowledge that you have both read and understood all text presented to you in this form. Δ
