Basic Info

Membership Type
Entering Year
Full/Part Time
Full/Part Time
A $50 Membership Fee per semester applies for Part Time employment
Smoker

Contact Information

Address

Emergency Contact

Emergency Contact

Emerson College Fitness Center Release, Waiver of Liability and Indemnity Agreement

IN CONSIDERATION of being permitted to enter an Emerson College Fitness Center (hereafter the Fitness Center) for any purpose, including, but not limited to observation, participating in physical activities or using facilities or equipment in any way, I, on behalf of myself, my personal representatives, heirs, assigns, and next of kin, hereby acknowledge, agree, represent, and warrant with respect to any present or future entry into or use of that Fitness Center that:

  1. Immediately upon entering, I will inspect the facilities of the Fitness Center, and I further warrant that such entry into the Fitness Center for observation, participation in physical activities or use of any facilities or equipment constitutes an acknowledgment that I find and accept same as being safe and reasonably suited for the purposes of such observation, participation or use.
  2. I am aware that the Fitness Center has facilities and equipment for activities including, but not limited to, weight training, walking, stair-climbing, jogging and running, rowing, and aerobic activities. I understand that participation in physical activities and the use of facilities or equipment at the Fitness Center involves inherent risks, including but not limited to, death, serious neck and spinal injuries resulting in complete or partial paralysis, heart attacks, and injury to bones, joints, or muscles. I represent that I am voluntarily observing or participating in Fitness Center activities and using Fitness Center facilities or equipment with full knowledge of all potential dangers involved therein and I further understand that the Fitness Center is an unattended facility and there are no Emerson College representatives or staff assigned to monitor my activities at the Fitness Center. I hereby assume full responsibility for and risk of bodily injury, death or property damage (whether due to ordinary negligence or otherwise) arising in connection with my observation, participation in physical activities and use of Fitness Center facilities and equipment.
  3. I represent to Emerson College that I am physically fit to perform those activities which I may undertake to perform at the Fitness Center and that I am solely responsible for all health risks associated with such activities.  I understand that Emerson College recommends that I seek approval from a physician before participating in such activities.  Either I have had a physical examination and have received a physician’s permission to participate in these activities, or I have decided to participate in these activities without the approval of my physician.  I understand that any evaluation or assessment of my physical fitness and any recommendation of activities made by the Fitness Center shall not be a substitute for obtaining such evaluation, assessment or recommendation from my physician before undertaking a physical exercise program or engaging in any of the activities at the Fitness Center.  I understand that any information about my physical condition that I provide to the Fitness Center is for informational purposes only and that Emerson College is not responsible for determining my physical fitness.
  4. I understand and agree that my use of the Fitness Center is voluntary and only to be undertaken on my own personal time.  If am an employee, I understand that my use of the Fitness Center is not within the course or scope of my employment. 
  5. I HEREBY RELEASE, WAIVE, DISCHARGE AND COVENANT NOT TO SUE Emerson College, its directors, officers, employees, independent contractors and agents (hereinafter referred to as Released Parties) from any and all liability for loss or damage, and any claim or demands therefore on account of injury to my person or property or resulting in my death, whether caused by the ordinary negligence of the Released Parties or otherwise arising in connection with my presence in, upon or about the Fitness Center or my observation, participation in physical activities or the use of the facilities or equipment of the Fitness Center.
  6. I HEREBY AGREE TO INDEMNIFY AND SAVE AND HOLD HARMLESS the Released Parties from any loss, liability, damage or cost (including but not limited to attorney fees) they may incur arising in connection with my presence in, upon or about the Fitness Center or my observation, participation in physical activities or the use of the facilities or equipment of the Fitness Center and whether due to my negligence or otherwise.
  7. I understand that this RELEASE, WAIVER AND INDEMNITY AGREEMENT is intended to be as broad and inclusive as permitted by the laws of the state and agree that if any portion is held invalid, the remainder of the waiver will continue in full legal force and effect. I confirm that I am at least 18 years of age, am freely signing this agreement, and that no oral representations statements or inducements apart from this written agreement have been made. I have read this form and fully understand that by signing this form, I am giving up legal rights and remedies that I might have now or in the future. I understand that my information will be kept secure and in confidence. The information contained herein shall be used for the sole purpose of assisting the staff in the evaluation of my safety for participation. External disclosures of this information will be limited to valid legal requests by law enforcement authorities and government agencies, legal proceedings where disclosure is necessary to protect the interest of the Fitness Center and Emerson College in subpoenas and similar legal process.
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Physical and Medical Information

Physical and Medical Information

To help us better understand your physical and medical limitations when participating in physical activities and to obtain the best help for you in the event of an emergency, please complete the following.*

(Please explain any YES answers in the space provided below.)

Do you have any significant medical illnesses which have required the regular care of a doctor? Please explain *
Do you have any allergies or have you had any bad reactions to any drugs. Which ones and what effect *
Have you been hospitalized in the past 5 years for an emergency or for serious medical reasons? Please explain *
Do you take any medications regularly that would be important for the staff to know about in the event of an emergency? Please explain *
Have you ever been told by a doctor that you have: epilepsy, diabetes, high blood pressure, asthma or lung disease, ulcers or stomach trouble, heart disease? Please elaborate *
Have you ever been diagnosed with any significant foot, leg or back problems, any other diseases or conditions which could affect your use of the Fitness Center? Please explain *
Physician's First Name / Physician's Last Name

OR

*This information is confidential. The information will not be used to discriminate against you in violation of any employment laws. In reviewing the information on this form and/or providing any recommendations regarding fitness regimen, neither Emerson College nor the employees of the Fitness Center is making any representation or assurance regarding your physical condition, ailments, or capacity to use the fitness facilities.