Acknowledgement of Risk/Consent to Treat
Contact Information
Name
*
First Name
Last Name
ODU Student Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
UIN
*
Date of Birth
*
Sport Club - please select one club from the list below. If you are joining multiple sport clubs, you will need to complete a separate form for each sport club.
*
Baseball
Basketball - Women
Field Hockey
Golf
Ice Hockey
Lacrosse - Men
Lacrosse - Women
Rowing
Rugby - Men
Rugby - Women
Soccer - Men
Soccer - Women
Softball
Swimming
Tennis
Ultimate
Volleyball - Men
Volleyball - Women
Gender
*
Male
Female
Other
Are you a first generational student?
*
Yes
No
Are you a returning sport club member? If so, what sport club were you a part of?
*
Emergency Contact Information
Name
*
First Name
Last Name
Relationship to Club Member
Daytime Phone Number
*
-
Area Code
Phone Number
Evening Phone Number
*
-
Area Code
Phone Number
I agree to provide a photo copy of my health insurance card to the Recreation & Wellness department within 5 business days from submitting this form. I understand that failure to do so will render me ineligible to participate in club sponsored activities.
*
Initial to agree
Acknowledgement of Risk
I desire to participate in activities sponsored by the Old Dominion University Recreation & Wellness Department. This participation is voluntary on my part.
*
Initial to agree
I understand that participation in any type of recreational sports activity carries with it an inherent possibility of injury. This includes injury from contact with others and/or the playing environment, aggravation of pre-existing injuries and/or conditions, and effects of overexertion and heat injury
*
Initial to agree
I fully and freely assume all foreseeable risks associated with the activities in which I have enrolled or will enroll, and do hereby release Old Dominion University, its employees, agents, contractors, successors and assigns, from any and all actions, claims, lawsuits, liabilities, causes of action or demands of whatever nature which might arise from my voluntary participation in these activities.
*
Initial to agree
SARS-CoV-2
The SARS-CoV-2 variant of the Coronavirus is an extremely contagious virus that spreads easily through person-to-person, community, and surface contact. Infection by this virus can cause the disease known as COVID-19, which can lead to severe illness, personal injury, permanent disability, and death. Federal and state authorities recommend physical distancing as a means to prevent the spread of the virus. We encourage all participants to be fully vaccinated with FDA approved vaccines prior to participating in RECREATION & WELLNESS programs. Some programs and services will require vaccination for participation.
Initial to agree
I certify that I have had a physical examination within the last year and am physically fit to participate in the activities for which I have enrolled. ODU Sport Club Physical Forms are available on the Recreation & Wellness website.
*
Initial to agree
Please attach both pages of completed ODU Sport Club Physical Form here
*
Browse Files
Cancel
of
I certify that I have a medical insurance policy currently in effect, and that I will keep a medical insurance policy current during any club-related activity as a requirement for continued club membership and participation.
*
Initial to agree
Please attach BOTH SIDES (back and front) of your valid health insurance card here
*
Browse Files
Cancel
of
Consent to Treatment and Disclosure of Information
To be read and submitted by the Student-Athlete and the Parent/Guardian if the Student Athlete is under 18 years of age.
II hereby authorize the athletic trainers within the Old Dominion University Department of Recreation and Wellness, who are under the supervision of a physician, to render to me (or to my son or daughter if under 18 years of age) any preventive, first aid, rehabilitative or emergency treatment that they deem reasonably necessary to preserve and/or improve my health and well-being (or the health and/or well-being of my son or daughter). Authorization and consent is hereby granted to Old Dominion University Department of Recreation and Wellness including its Athletic Training Services staff, health care professionals, and consultants to obtain and release health information and records for treatment, payment, and health care operations purposes. I understand and agree that information about my injury/condition may be disclosed to staff and personnel of the Department of Recreation and Wellness in relation to my participation in any physical activity.
*
Initial to agree
I affirm, as a member of this officially recognized sport club, that I have read and understand all rules, regulations and responsibilities that pertain to our club according to the Recreation & Wellness Department Sport Club Handbook and Old Dominion University.
*
Initial to agree
I hereby certify that I have carefully read this form and fully understand its contents. If I did not fully understand the contents of this form, I have sought and obtained legal advice concerning its significance, and have gained an understanding of the meaning of the form before signing it. I also certify that I am over eighteen (18) years of age, and reaffirm all certifications made on this form.
*
Initial to agree
I pledge to support the Honor System of Old Dominion University.
*
Initial to agree
Submit
Should be Empty: