Texas Southern University

expense of any kind, including without limitation claim of negligence, that develops relating to or arising out of the Wellness Activities Acknowledgment Activity or User’s participation in the and Waiver Form Activity. Activity: 4. Affirmation. User knowingly represents that: ______a. physical exercise can be a strenuous ______activity with inherent hazards; Date(s) of Activity: b. unsupervised Facility use can result in ______Risk; ______c. University has urged User – before For questions regarding Activity availability, contact Kathe engaging in any Activity – to obtain a Snow in Human Resources Development at declaration from a competent health care [email protected]. provider indicating whether physical exercise is appropriate for User; 1. Definitions. For this document’s purposes, d. a competent health care provider has: the following definitions will apply: i. affirmed specifically User’s suitability “Activity” means any voluntary wellness to engage in physical exercise and activity/event sponsored by the University use exercise equipment; and (defined below) that is open to any User ii. not advised User either not to engage (defined below) – including any related facility in physical exercise or not to use use – as well as any other physical activity exercise equipment; sponsored by the University. e. University makes no representation or “University” means the University of Hartford, warranty concerning the safety of the including its regents, officers, employees, Activity (including any related facility’s volunteers and agents. design, manufacture, installation, “User” means each eligible individual layout configuration or functioning). identified on the reverse of this form intends 4. Representations. Each signature on the to participate in an Activity. If an employee of reverse side of this form indicates that the the University is a User, then that employee’s identified User: spouse, same-sex partner or dependent child a. has carefully read and understood this is also eligible to be a User if also at least 18 document and its associated materials; years of age. b. by signing, is giving up substantial “Risk” means collectively any property legal rights; damage or personal injury (physical, c. has not been induced to sign this emotional or mental), whether minor or agreement by any promise or serious, up to and including paralysis or even representation; and death. d.. signs this document voluntarily and of 2. Liability. Excluding any harm caused by the that User’s own free will. University’s intentional or reckless conduct, User: 5. Legal Construction. User intends this document to be construed in accordance with a. knowingly accepts all legal liability for the laws of the State of Connecticut. If any each Risk associated with the Activity; provision of this document is held illegal or and unenforceable, then User intends the b. releases, waives, discharges and holds remaining portions not to be affected by that harmless the University from and against holding. any claim, demand, liability, controversy or cause of action, damage, cost or *REQUIRED USER* (UNIVERSITY EMPLOYEE): ADDITIONAL USER (SPOUSE/SAME-SEX PARTNER AND/OR DEPENDENT CHILD OVER 18 Name: ______YEARS OF AGE): ___Department: Name: ______E-mail: ___ Relationship to Employee: ______Phone and/or Extension: E-mail: ______Signature: Phone and/or Extension: ______Date:______Signature: Emergency ______Contact:______Date:______Telephone Number: Emergency ______Contact:______Telephone Number: ADDITIONAL USER (SPOUSE/SAME-SEX ______PARTNER AND/OR DEPENDENT CHILD OVER 18 YEARS OF AGE): ADDITIONAL USER (SPOUSE/SAME-SEX PARTNER AND/OR DEPENDENT CHILD OVER 18 Name: ______YEARS OF AGE): ___ Relationship to Employee: Name: ______E-mail: ___ Relationship to Employee: ______Phone and/or Extension: E-mail: ______Signature: Phone and/or Extension: ______Date:______Signature: Emergency ______Contact:______Date:______Telephone Number: Emergency ______Contact:______Telephone Number: ADDITIONAL USER (SPOUSE/SAME-SEX ______PARTNER AND/OR DEPENDENT CHILD OVER 18 YEARS OF AGE): ADDITIONAL USER (SPOUSE/SAME-SEX PARTNER AND/OR DEPENDENT CHILD OVER 18 Name: ______YEARS OF AGE): ___ Relationship to Employee: ______Name: ______E-mail: ___ Relationship to Employee: ______Phone and/or Extension: ______E-mail: ______Signature: Phone and/or Extension: ______Date:______Signature: Emergency ______Contact:______Date:______Telephone Number: ______Emergency Contact:______Telephone Number: ______ADDITIONAL USER (SPOUSE/SAME-SEX PARTNER AND/OR DEPENDENT CHILD OVER 18 YEARS OF AGE):

Name: ______Relationship to Employee: ______

E-mail: ______Phone and/or Extension: ______

Signature: ______Date:______

Emergency Contact:______Telephone Number: ______