The official hotel of
VT Sport Clubs


 
Division of Student Affairs



Assumption Of Risk Form
Personal Information
Select Club:
First Name
Last Name
Middle Initial
Student ID #
Date of Birth Format = MM/DD/YYYY
E-Mail Address
Gender
Race
Your VT Address < Address
City / State / Zip
  < Phone Number (XXX) XXX-XXXX
Permanent Address < Address
City / State / Zip
  < Phone Number (XXX) XXX-XXXX
Medical Information
Allergies
Medication Taken
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by your doctor? If yes, please describe.
Do you feel pain in your chest when you do physical activity? If yes, please describe
In the past month, have you had chest pain when you were not doing physical activity? If yes, please describe.
Do you lose your balance becasue of dizziness or do you ever lose consciousness? If yes, please describe.
Do you have a bone or joint problem that could be made worse by physical activity? If yes, please describe.
Is your doctor currently perscribing drugs (for example, water pills) for blood pressure or a heart condition? If yes, please describe.
Do you know of any other reason why you should not do physical activity? If yes, please describe.
Any Other Information:
Emergency Contacts
Contact 1 < Name
< Relation < Home Phone
< Cell Phone < Work Phone
Contact 2 < Name
< Relation < Home Phone
< Cell Phone < Work Phone
Health Insurance Information
Insurance Company
Policy Number
Phone Number
Form Confirmation
I agree to indemnify, defend and hold harmless, Virginia Polytechnic Institute and State University (The University) and their officers, agents, and employees from any claims, dangers, and actions of any kind or nature, whether at law or in equity, arising from my participation in the club I have selected above, provided that such liability is not attributable to the sole negligence of the University. I realize that my participation in this activity involves risk of injury, including but not limited to tendonitis, strains, bursitis, fractures, delayed muscle soreness, contusions, abrasions, serious eye damage, and even the possibility of death. Also, I recognize that there are many other risks of injury including serious and disabling injuries, which may arise due to my participation in this activity, and that it is not possible to specifically list each and every individual injury risk. By signing this form I desire, consent and voluntarily choose to take part in all such activities. Knowing the material risks are appreciating, knowing and reasonably anticipating that other injuries and death is a possibility, I assume all the risks normally incident to the nature of the activities and agree that the University or any of its officers, agents, and employees conducting such activities will not be responsible for any damages or injuries resulting to me. Furthermore, I also confirm that I have appropriate healthcare insurance for this activity. Also, I understand that any injury incurred and the resulting medial expense from that injury will be my responsibility and the University will not be responsible for any related expenses, other than those incurred at the University’s Student Health Services.

* For certain medical conditions, the Sport Club Office / Department of Recreational Sports may require you to obtain a letter from your physician giving approval for you to be a sport club participant.

* This form must be kept current and accurate throughout the year. Resubmit it to make changes if necessary.
Your Full Name
Date Format = MM/DD/YYYY
Initials This will serve as your official signiture