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Agreement to Participate
This form is to be used for alumni contests, clinics, and outside group activities.
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| Applicant's name: |
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Age: |
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| Address: |
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Sport: |
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I am aware that playing or practicing in any sport can be a dangerous activity involving many risks or injury. I understand that the dangers and risks of playing or practicing in the above sport include, but are not limited to, death, serious neck and spinal injuries which may result in complete or partial paralysis or brain damage, serious injury to virtually all bones, joints, ligaments, muscles, tendons, and other aspects of the muscular-skeletal system and serious injury or impairment to other aspects of my body, general health and well being. |
Because of the dangers of participating in the above sport, I recognize the importance of following all instructions by the coach. |
This agreement applies specifically to the following date(s): |
In consideration of the University of Delaware (UD) permitting me to practice or play the above sport and to engage in all activities related to this sport, I hereby voluntarily assume all risks associated with participation and agree to exonerate, save harmless and release the UD, its agents, servants, trustees and employees from any and all liability, medical expenses, claims, causes of action or demands of any kind and nature whatsoever which may arise by or in connection with my participation in any activities related to the sport(s) indicated above. |
I agree that in case of an accident involving me (my child) while participating in this activity, and with full awareness that this activity may involve risk or injury, I release the University of Delaware, its trustees, employees and servants from any and all liability. In case of an emergency, I give permission to the appropriate event personnel to have my child properly transported to a medical facility for care. |
I understand that the University of Delaware does not provide medical insurance and that I will be responsible for all medical expenses incurred. |
The terms hereof shall serve as a release and assumption of risk for my heirs, estate, executor, administrator, assignees, and all members of my family. |
I hereby agree to submit any disputes that may arise between myself and UD, its agents, servants, trustees and employees, in connection with my activities at UD, to binding arbitration before three arbitrators, in accordance with the Rules of the American Arbitration Association. |
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| Signature of participant |
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Note: Signature may be that of participant only, if 18 years of age or over, otherwise it must also be signed by both parents or legal guardians.
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| Signature of father/legal guardian |
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| Signature of witness |
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| Signature of mother/legal guardian |
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| Signature of witness |
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| Emergency Health Information |
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| Family physician's name: |
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Indicate any serious medical conditions:
(allergies, recurring illnesses, disabilities, chronic illness, etc.) |
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| Please list names of medication currently taking and for what medical condition: |
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Date of most recent tetanus immunization:
(if more than 10 years ago, a booster shot is recommended) |
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| Applicant is allergic to: |
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Penicillin Aspirin
Other:
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| Medical insurance company: |
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| Policy number: |
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| Expiration date: |
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