HomeSafetyAthletic Camps Utah Tech University Athletic Camps Waiver Athletic Camps Medical Information Participant's First Name * Participant's Last Name * Is participant over 18? Yes No Camp Name * Baseball CampsMen’s BasketballWomen’s Basketball CampsFootballMen’s SoccerWomen’s SoccerSoftballWomen’s SwimmingWomen’s Volleyball Participant's Team * Camp Starts * Camp Ends * Name of Participant’s Personal Physician: * Physician’s Phone Number * Personal Health/Accident Insurance Carrier * Policy Number * Will your participant take any medication during this program? Yes No List any medications Does participant have any physical conditions that may affect full participation in the activity? Yes No Please explain Does participant use a medical device? Yes No (e.g., braces, glasses, contact lenses, hearing aid, etc.) Please list medical device(s) used Does participant have special medical conditions? Yes No (e.g., food allergies, asthma, diabetes, heart condition, etc.) Please list any medical conditions Emergency Contact Name Phone patron assumption of risk and release of liabilty for dixie state university campus activities Assumption of Risk: I understand that engaging in any form of physical exercise, using DSU campus facilities for any purpose could pose a serious risk to my health or cause death and that this risk is in part dependent on my particular level of fitness, medical condition and exercise choices. I understand that my participation in this Activity and/or use of DSU campus facilities, involves risks and I assume the risks that include but are not limited to physical or psychological injury, pain, suffering, illness, disfigurement, temporary or permanent disability (including paralysis), economic or emotional loss, and/or death. I understand that these injuries or outcomes may arise from my own or other’s actions, inaction, or negligence or the condition of DSU campus facilities. I assume all related risks, both known or unknown to me, of my participation in this Activity, and use of DSU campus facilities and further agree to accept all DSU campus facilities requirements for use of the facilities and to follow the instructions given by supervisory personnel at DSU campus facilities. I am voluntarily participating in this Activity and may be using DSU campus facilities and I acknowledge and fully assume the risks associated with my participation and my use of DSU campus facilities. Physical Health Considerations: I understand it is strongly recommended that I first consult a physician to establish whether it is appropriate for me to participate in this Activity. Further, I agree that if I notice any change in my physical condition that could indicate a health risk if I continue to participate, I will promptly consult a physician and follow my physician’s recommendations about my continued participation in this Activity. Health Certification: I certify that I am physically capable and sufficiently healthy to be engaging this Activity, both mental and physical, at DSU campus facilities, and that I have no health care condition which would interfere with my ability to safely participate. Acknowledgement of DSU Rules: I understand it is my responsibility and it is required to read, become familiar with, and to follow the DSU campus facilities standards, rules, and regulations and to comply with the etiquette standards, rules, and regulations of the DSU. I will follow all posted rules, which rules may be changed from time to time by officials. If I violate these rules, I assume all risk of injury, illness, damage or loss to me or my property or to DSU property. I understand that my failure to follow all posted rules can result in the revocation of my right to participate in this Activity. Indemnification and Hold Harmless: I agree to indemnify and hold Dixie State University, the Board of Trustees, directors, officers, employees, and agents (collectively referred to as “DSU”) harmless from any and all claims, actions, suits, procedures, costs, expenses, damages and liabilities, including attorney’s fees, arising out of my participation in this Activity or use DSU campus facilities and to reimburse DSU for any such expenses incurred. Release of Liability and Waiver: In return for being permitted to participate in this Activity and for being permitted to use DSU campus facilities, including any associated use of the premises, facilities, staff, equipment, and services of DSU facilities and DSU, I, for myself, heirs, personal representatives, and assigns, do hereby release, waive, discharge, and promise not to sue DSU, the Board of Trustees, directors, officers, employees, and agents (collectively referred to as “DSU”) from liability from any and all claims, including the negligence of DSU, resulting in personal injury (including death), accidents or illnesses, and property loss in connection with my participation in the Activity and use of DSU campus facilities. Governing Law and Severability: I understand that this document is written to be as broad and inclusive as legally permitted by the State of Utah and agree that if any portion is held invalid or unenforceable, I will continue to be bound by the remaining terms. I agree that this Agreement shall be governed by the laws of the State of Utah, and any disputes arising out of or in connection with this Agreement shall be under the exclusive jurisdiction of the state District Courts of the State of Utah. Understanding and Acknowledgement: I acknowledge that I am aware of potential risks related to my participation in the Activity and in my use of DSU campus facilities. I have read all previous paragraphs, including the release of liability and waiver, assumption of risk, and indemnity agreement, know, fully understand its terms, acknowledge these and other risks that are inherent to the participation in the Activity and in my use of DSU campus facilities and understand that I am giving up substantial rights, including my right to sue. I acknowledge my participation and use of DSU campus facilities is voluntary, that I knowingly assume all such risks, and that I am signing the agreement freely and voluntarily, and intend by my signature to be a complete and unconditional release of all liability to the extent allowed by law. No other representations concerning the legal effect of this document have been made to me. I am 18 years or older. I have read this document and fully and completely understand the potential risks that may be associated with the program, activity or course. I have read this two-page document and I am signing this document freely and voluntarily. Assumption of Risk and Release Related to COVID-19 Please initial each of the following statements to indicate your understanding and agreement: Assumption of Uncertainties: I understand that the program, activity or course may be shortened or altered unexpectedly due to the evolving changes associated with the COVID-19 pandemic. Assumption of Risks: I understand and acknowledge the highly contagious nature of COVID-19 and I understand that enrollment and participation in the program, activity or course, involve risks and I assume the risks that I may be exposed to, or infected by, COVID-19 by my participation in the program, activity or course. I assume all related risks, both known or unknown to me, of my participation in the program, activity or course and further agree to accept all program, activity or course requirements for participation and to follow the instructions given by supervisory personnel involved in the program, activity or course. I am voluntarily participating in the program, activity or course, and I acknowledge and fully assume the risks associated with my enrollment and participation in the program, activity or course. Indemnification and Hold Harmless: I agree to indemnify and hold Dixie State University, the Board of Trustees, directors, officers, employees, and agents (collectively referred to as “DSU”) harmless from any and all claims, actions, suits, procedures, costs, expenses, damages and liabilities, including attorney’s fees, arising out of my involvement in the program, activity or course and to reimburse DSU for any such expenses incurred. Health Certification: I certify that I am physically capable and have received health care clearance for participating in the program, activity or course, and that I have no health care condition which would interfere with my ability to safely participate. COVID-19-Related Symptoms: I understand that symptoms of COVID-19 include but are not limited to: fever, fatigue, cough, shortness of breath or difficulty breathing, sore throat, chills, new loss of taste or smell. COVID-19-Related Requirements: I understand that (1) if I show any signs of illness or symptoms of COVID-19, or (2) if I have been exposed to or test positive for COVID-19 then I will not report to the program, activity or course, until I have been cleared by a physician and I have followed all the procedures for the program, activity or course and DSU following CDC and/or health department guidelines. I will report any potential illness, exposure, or positive COVID-19 test to the program, activity or course supervisor immediately. I agree to follow all safety procedures in accordance with the program, activity or course’s and DSU’s guidelines. Release of Liability and Waiver: In return for being permitted to enroll and participate in the above program, activity or course, including any associated use of the premises, facilities, staff, equipment, transportation, and services of Dixie State University, I, for myself, heirs, personal representatives, and assigns, do hereby release, waive, discharge, and promise not to sue Dixie State University, the Board of Trustees, directors, officers, employees, and agents (collectively referred to as “DSU”), from liability from any and all claims, including the negligence of DSU, resulting in being infected with COVID-19 or any other illness and the resulting effects of said illness, including any injury (including death) or any other loss in connection with my participation in the program, activity or course and any use of DSU’s premises and facilities. Governing Law and Severability: I understand that this document is written to be as broad and inclusive as legally permitted by the State of Utah and agree that if any portion is held invalid or unenforceable, I will continue to be bound by the remaining terms. I agree that this Agreement shall be governed by the laws of the State of Utah, and any disputes arising out of or in connection with this Agreement shall be under the exclusive jurisdiction of the state District Courts of the State of Utah. Understanding and Acknowledgement: I acknowledge that I am aware of potential health risks related to COVID-19 or other illnesses during my program, activity or course. I have read all previous paragraphs, including the release of liability and waiver, assumption of risk, and indemnity agreement, know, fully understand its terms, I agree to the patron assumption of risk and release of liabilty for Dixie State University campus activities * I Agree I agree to the assumption of risk and release related to COVID-19 * I Agree Participant Signature * Clear Parent/Guardian Name * Parent/Guardian Signature * Clear Submit
