Peterson Recreation/Concannon Fitness Centers Membership Application/Agreement

Last Name:

First Name:

Middle Initial:

Email Address:

Phone Number:

Membership Type

Please check the following box that pertains to your status:

FT Fac/Staff Member	FT Graduate Assistant
Retired/Emeritus	Dominican Community
FT Grad Students ($50 membership fee per semester)	FT SCE Students ($50 membership fee per semester)

All applicants, regardless of membership type, must present a valid PC ID card or Membership Card to access the facilities.
RELEASE AND HOLD HARMLESS AGREEMENT

By my signature below, I agree to abide by the rules and regulations of the Peterson Recreation and Concannon Fitness Centers, as outlined in the Recreational Sports Department Handbook, as well as follow all directives from Recreational Sports staff members.

By my signature below, I also hereby recognize that I intend to pursue fitness and recreational activities at the Peterson Recreation and Concannon Fitness Centers and/or adjoining fields and courts. I recognize and acknowledge that the Department of Recreational Sports of Providence College does not carry any special health and/or medical insurance that would provide coverage for my participation in such fitness and recreational activities in the event that I should sustain an accidental injury while participating in said activities. I recognize that there are inherent risks in such activities including injury, disability, disease, and death, which I hereby voluntarily assume. I also understand that it is incumbent upon me not to undertake those activities which I am not physically fit enough to perform or which are contrary to any professional medical advice I may have received. Therefore, in consideration of my willingness to participate in such programs, I hereby discharge Providence College, it’s governing board, officers, staff, coaches, and other employees from all obligations, liabilities, claims, demands, costs, and expenses, including but not limited to attorney’s fees, arising out of, or in any way connected with, any bodily injury or death sustained by my participation, whether such injury results from the negligence of the aforesaid person or from some other cause.

Applicant's Signature:

Date:

Emergency Contact Information:

Name:

Phone:

Group Exercise Waiver and Health Insurance Notification

By checking, I understand that participating in a group exercise program can be a dangerous activity involving many risks or injuries. I understand that in participating, I hereby voluntarily assume all risk associated with participation in said programs and do herby agree to exonerate and save harmless Providence College, its agents, and employees of any responsibilities in connection with my participation in the group exercise program. I attest that I am in good health and physically able to undertake a general sports program or activity. Furthermore, I certify that I have not been advised by a qualified medical authority to abstain from such physical activity.

I also understand that the Student Health Center does not treat major injuries and may not be able to provide medical services and treatment required by an injury sustained while participating in group exercise. In the event of such an injury, I understand that it is my responsibility to pay for such treatment and services either through my health insurance carrier, or through out-of-pocket payment. I understand that Providence College does not assume any responsibility for payment of medical treatment or services not covered by my own health insurance or not offered through the Student Health Center.

I hereby certify that I have read and understand the above sections and affirm that I am covered by an active insurance policy. I understand that failure to sign this waiver can restrict me from participating in the Providence College group exercise program.

I agree

Yes