Sport Club Participation Form

Sport Club Participation Form
Please provide all of the required information. If you have any questions or require assistance, please contact the Competitive Sports Office at 618-453-1284.
Date Submitted*

MonthDayYear
Date
Sport Club Name*
Contact Information
Name*

First NameLast Name
DAWG Tag or RSS Member ID*
Students, please provide your nine-digit DAWG Tag without the SIU prefix. ex: 850121234. Members, please prove you member ID as follows: 9100XXXXX.
Date of Birth*

MonthDayYear
Date
Email (SIU Email Preferred)*
example@example.com
Phone Number*
Please enter a valid phone number.
Current Local Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Assumption of Risk, Waiver, and Release from Liability
In consideration of the use of the property, facilities, services, programs, activities and events provided by SIUC Recreational Sports and Services, including any travel related thereto, the undersigned agrees as follows:
1. RISK FACTORS. The undersigned understands and acknowledges that the use of equipment and facilities provided by SIUC Recreational Sports and Services and participation in the Recreational Sports and Services Programs (intramurals, Extramural Participation, Sport Clubs, Physical Sports, Weight and
  Cardiovascular training, Base Camp Programs, Instructional Programs, Aquatic Programs, Special Populations Programs, RSS Fitness Programs and any
  other programs and services sponsored by SIU Recreational Sports and Services and related travel) involves risk such as, but not limited to, the following which might result from the use of the equipment or facilities, from the activity itself, from the acts of others, or from the unavailability of emergency
  medical care: RISK OF PROPERTY DAMAGE, BODILY INJURY, AND POSSIBLY DEATH.
2. ASSUMPTION OF THE RISK. The undersigned ASSUMES ALL RISKS WHICH ARE FORESEEABLE AND INVOLVED WITH OR ARISE OUT OF THE USE OF THE
  EQUIPMENT OR FACILITIES, THE ACTIVITY ITSELF, THE ACTS OF OTHERS, OR THE UNAVAILABILITY OF EMERGENCY CARE, including but not limited to, those RISK FACTORS described in Section 1 above.
3. ACKNOWLEDGMENT OF POLICIES AND PROCEDURES. The undersigned acknowledges reading and knowing all of the policies and procedures relating to the activities, facilities, and/or equipment and understands that the safe proper use of the facilities, equipment, or participation in the activity is dependent upon carefully following such policies and procedures.
4. PREREQUISITE SKILLS AND TRAINING. The undersigned acknowledges that he or she has the requisite skill, qualification, physical ability and training and necessary to properly and safely use the equipment and facilities and to participate in the activity itself. The undersigned agrees that if he or she has any questions as to what skills, qualifications or training is necessary to properly use the equipment, facility, or participate in the activity itself, then they shall direct such questions to the appropriate Staff member on-site.
5. RELEASE. The undersigned RELEASES the State of Illinois, the trustees of Southern Illinois University Carbondale, Recreational Sports and Services and all of their officers, employees, and agents and agrees NOT TO SUE them on account of or in conjunction with any claims, causes of action, injuries, damage, or cost of expenses arising out of the activity, including those based on death, bodily injury or property damage whether or not caused by the negligence or other fault of the parties being released.
6. WAIVER. The undersigned waives the protection afforded by any statute or law in any jurisdiction.
7. INDEMNIFY AND DEFEND, The undersigned agrees to INDEMNIFY AND DEFEND the State of Illinois, the trustees of Southern Illinois University Carbondale, the SIU Recreational Sports and Services and all of their officers, employees, and agents (hereinafter jointly referred to as "indemnities11) against, and hold them harmless from any and all claims, causes of action, damages, judgments, cost or expenses, including attorney fees which in any way arise from the activity or this agreement and which include but are not limited to damages to or destruction of any property of the indemnities of any others, injury or death to the undersigned or anyone else or any liability arising from the act or negligent act of the indemnities, the undersigned or anyone else.
8. PAY. The undersigned agrees to pay for any and all damages to any property or indemnities caused by the undersigned either negligently, willfully, or otherwise.
9. LEGAL FEES. In the event of any controversy, claim or dispute between the parties arising out of or relating to this agreement or the breach thereof or the activity, the prevailing party shall be entitled to recover from the losing party reasonable expenses, attorney fees, and cost.
10. REPRESENTATIVES. The undersigned enters into this agreement for him/herself, his/her heirs, assigns, and legal representatives.
11. EMERGENCY TREATMENT CONSENT. The undersigned, as a participant in the subject activity, hereby consent to medical treatment in a medical emergency where the undersigned is unable to consent to such treatment.
12. INSURANCE. The undersigned understands the Recreational Sport and Services department does not carry participant insurance. The undersigned is encouraged to have a physical examination and purchase health insurance prior to any and all participation.
13. ACKNOWLEDGMENT. The undersigned has read and understands this agreement and realizes it relates to surrendering and releasing valuable legal rights and does so freely and voluntarily.
Name*

First NameLast Name
Signature*

Clear
Date*

MonthDayYear
Date

Expectations and Responsibilities
Expectations & Responsibilities
- I will represent Southern Illinois University Carbondale in a positive manner.
- During in-person and virtual events, I will demonstrate respect for and pursue amicable relationships with my club members, my club officers, contest officials, opponents, coaches, spectators, and Competitive Sports staff.
- Follow the policies and procedures set forth by the Competitive Sports Office, Recreational Sports and Services, the Office of Student Engagement, and the Office of Student Rights and Responsibilities.
Reporting Responsibilities
- I understand that I am required to report the following to the University:
  - Acts of self-harm or harm to others
  - Discrimination
  - Harassment
  - Hazing
  - Intimidation
  - Sexual misconduct
  - Verbal, written, or physical abuse
  - Violations of the RSO Handbook and Sport Club Handbook.
  - Violations of the Student Conduct Code
Resources

Office of Student Rights and Responsibilities

Student Rights and Responsibilities administers a fair, educational, and consistent conduct process that holds students and student organizations accountable to the Student Conduct Code. The office works to provide opportunities for students to reflect on their behavior and grow in the process.

Office of Student Engagement

The Office of Student Engagement’s purpose at Southern Illinois University Carbondale is to engage students on campus through meaningful involvement opportunities that enable students to gain leadership experience while also serving the campus community.

Sport Club Program

Sport clubs at SIU offer all students the chance to participate in an extracurricular activity that promotes positive self-development, optimal well-being, and an increased awareness of personal and social diversity.

Emergency Contact Information
Emergency Contact Name*

First NameLast Name
Phone Number for Emergency Contact*
Please enter a valid phone number.
Current Address of Emergency Contact*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact's Relationship to Member*

Acknowledgement
My signature indicates that I understand that violations of University policies and procedures may result in programmatic penalties, administrative sanctions. and/or organizational sanctions. I also understand that I may be held responsible for failing to report violations to the University.

My signature indicates that the medical history information provided on this form is accurate and complete. At any time, I can request via email (siucompsports@siu.edu) that my medical history information is immediately discarded.

My signature verifies that (a) I am a currently enrolled SIU Student that has paid the General Student Fee, (b) a currently enrolled SIU Student that has purchased the inactive student membership, or (c) a current RSS member that is at least eighteen years of age and has purchased a semester or annual membership.
Please sign here.*

Clear
Should be Empty:

	Yes	No
Anemia
Diabetes
Kidney Disease
Liver Disease
Headaches/Migraines
Chest Pains
Mental Health Issues (e.g. depression, anxiety, personality disorders)
Exercise-induced blackouts, fainting, and/or dizziness
Exercise-induced breathing difficulties
Concussions or other Traumatic Brain Injuries (TBIs)
Neurological Incidents (e.g. stroke, aneurysm, seizures, etc.)
Pulmonary Diseases and Conditions (e.g. heart murmur, irregular heartbeat)
Cardiovascular Diseases and Disorders (e.g. high blood pressure)

Sport Club Participation Form

Contact Information

Assumption of Risk, Waiver, and Release from Liability

Expectations and Responsibilities

Medical History

Emergency Contact Information

Acknowledgement