CLUB SPORTS INDIVIDUAL PARTICIPANT REGISTRATION- DEPARTMENT RISK STATEMENT

Transcription

1 CLUB SPORTS INDIVIDUAL PARTICIPANT REGISTRATION- DEPARTMENT RISK STATEMENT The following statement is to be read carefully by individuals who are enrolled in and/or participating in activities supervised by the staff of the Department of Campus Recreational Services (CRS) of the State University of New York at Binghamton. This consent will be binding on future registrations even if this form is not filled out upon renewal. If there is a change in a user s fitness level or health, it is the user s responsibility to inform CRS management prior to any participation. NAME (please print): CLUB: Acknowledgement of Risk: I,, am voluntarily agreeing to participate in activities sponsored by Campus Recreational Services or a Student Association chartered sports club. Certain activities require minimum levels of fitness, ability and health (physical, mental and emotional) and each person has a different capacity for participation in these activities. Participants are responsible for consulting a physician before starting any exercise program or physical activity. I understand that fitness and physical activities involve significant and inherent risks such as serious injury and even death. I understand that these types of injuries may result from one s own actions or the actions of others, or a combination of both. I understand and appreciate that there are a number of inherent risks involved that are beyond the control of the sponsoring agency and its staff. I understand that there is an inherent risk involved in TRANSPORTATION TO AND FROM an ACTIVITY SITE such as: injury or death related to vehicular accidents, slip, falls, unforeseen delays and schedule changes. I fully understand and accept all risks associated with participation in this activity. Informed Consent: I,, agree to abide by all of the posted & distributed rules, regulations, guidelines and verbal instructions as presented by the CRS staff, instructors or volunteers associated with the department. Any staff, instructor or volunteer may exclude from participation any participant who, in their judgment, has seriously impaired the ability of others to achieve the intended purpose or objectives of the class or activity. I agree that Binghamton University, its employees, and its agents shall not be liable for injury to users person or loss or damage to users personal property arising from or in any way resulting from the users participation in these activities, unless such an injury is caused by the negligence of the University, its employees, or its agents while acting within the scope of their duties. I understand that in the event of a serious medical emergency, I give permission to Binghamton University, CRS representative to seek emergency medical treatment for me even in the event that I am unconscious or otherwise cannot consent. I agree to accept financial responsibility for all medical treatment, rescue and related transportation. In registering as a participant of and in consideration of being permitted by Binghamton University to participate in activities offered by CRS, I agree that my name and/or picture MAY be used to promote the Binghamton University CRS programs, events and activities. I also am advised that the activity is conducted in a public place and I may be photographed. I release CRS from all forms of claims relating to the use of my name and picture. I HAVE CAREFULLY READ AND CONSIDERED THIS INFORMATION AND FULLY UNDERSTAND ITS CONTENTS. I AM AWARE THAT I AM RELEASING CERTAIN RIGHTS that I may have otherwise, and enter into this contract on behalf of myself and my family in consideration of being permitted to participate in Binghamton University Campus Recreational Services. I attest all information submitted by me is true and accurate to the best of my knowledge. I fully understand submitting misrepresented information, failing to disclose significant information, emitting facts, and/or falsifying documents may result in serious personal injury, death, university judicial and/or legal action against me. Signature & Date:

2 CLUB SPORTS INDIVIDUAL PARTICIPANT REGISTRATION- GENERAL INFORMATION NAME: (Please Print) Last First M.I. CLUB: DATE OF BIRTH: B-NUMBER: BU LOCAL ADDRESS: Street Apt. City State Zip Code PREFERRED PHONE NUMBER(S): PERMANENT ADDRESS: Street Apt. City State Zip Code CURRENT BU STATUS (circle appropriate status): Freshman Sophomore Junior Senior Grad. Faculty/Staff DO YOU HAVE A VEHICLE THAT MAY BE USED AS TRANSPORTATION TO/FROM CLUB EVENTS: YES NO DOES YOUR VEHICLE HAVE PROPER INSURANCE COVERAGE? YES - Exp. Date: NO INSURANCE COMPANY: POLICY NUMBER: MAKE: MODEL: YR: PLATE #: STATE: DRIVER LICENSE # (BEGIN WITH STATE): ARE YOU INTERESTED/AVAILABLE TO DRIVE A 12 PASSENGER VAN (RENTED AND/OR UNIVERSITY)? YES NO IF YES- DRIVER LICENSE #: STATE: ARE YOU INTERESTED/AVAILABLE TO DRIVE A 15 PASSENGER VAN (RENTED AND/OR UNIVERSITY)? YES NO IF YES- DRIVER LICENSE #: STATE: CERTIFICATION(S) (Circle all that apply)- if None, please state None : AED Certified- Expiration: CPR Certified- Type: Expiration: First Aid Certified- Expiration: Other: Expiration: MEDICAL INSURANCE COVERAGE (Check all that apply)- In order to participate, primary insurance is required. Club Sports carries a secondary catastrophic insurance that begins with a $30, deductible: [ ] My insurance is current, I am covered by the voluntary University Health/Accident Injury Insurance Policy. [ ] My insurance is current, I am covered by parent/guardian or personal policy. (Name and Policy Number below) Name of Company: Policy #: OFFICE USE ONLY: Entered as Volunteer: Date: Intials: > Club President or Co-President: >Other: > Club Vice President: > Club Captain or Co-Captain: > Club Driver (practices and/or games/tournament): : Reviewed August 2012

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4 CLUB SPORTS INDIVIDUAL PARTICIPANT REGISTRATION CONDUCT- HARASSMENT-HAZING- DISCIPLINARY ACTION OF INDIVIUALS & THE GROUP (CLUB) Conduct of all participants will be according to the rules and policies of the Student Conduct published by Binghamton University and the established guidelines of Club Sports and Campus Recreational Services. Harassment and Hazing: Club members are part of a community that supports individual integrity and celebrates its diversity. Binghamton University does not condone harassment directed toward any individual. Behaviors that denigrate a person or persons because of race, religion, sexual orientation, gender, age, or physical/mental disability will be dealt with quickly and severely. HAZING in any form will not be tolerated. Hazing is against the law and is defined as any action on or off campus intended to create mental or physical discomfort, embarrassment, ridicule, (e.g. shaving haircuts, eating or drinking excessively). Any action demanded of club members as initiation and/or team ritual that may harm or discomfort is considered hazing and will allow for the student/s responsible to be turned over to the proper authority. Note the following NY Law. In accordance with the State of New York s updated Rules of Student Conduct (Pursuant to Article 129-A [NYS Education Law 6430 (2)]; Student groups and organizations recognized administratively or by student government(s) and/or their officers may be charged with, and held responsible for violations of these conduct codes. Sanctions against the student organizations and its officers may include revocation of recognition of the group, loss of permission to use University facilities and the University name, as well as other appropriate sanctions. Disciplinary Action- Individual: Disciplinary action applied to any club sports participant/s may come from various sources, including but not limited to Judicial Affairs, based upon the severity of the violation of policy. If a club sport member/s has been reported to have taken any part in what is considered harassment or hazing, s/he will be temporarily suspended from the club effective immediately. The incident will be investigated and an administrative hearing will be scheduled between the Club Sports Review Committee, the student, the Club Sports administrator/s and any other University affiliated office (as necessary). The outcome of the investigation, meetings and/or hearings may result in many things, including but not limited to; participant may be fully reinstated, permanently suspended, or reinstated with stipulations. Based on the circumstances of the incident, the club in which the student is a member of may be suspended as well pending a decision. Individual club participants may be placed on probation or suspension by the Club Sports administration and Campus Recreational Services for the following reasons, but not be limited to (Note: Individual probation or suspension may be done by administration only, the Rules Committee may be relieved of review do to the sensitivity of personal issues, concerns, challenges involved): (a) Actions that violate the Rules of Student Conduct published by Binghamton University; (b) Actions that would discredit the University or the Division of Student Affairs; (c) Actions that would violate Club Sport policies and participant agreements; (d) Special circumstances that would impact the safety, participation, and/or overall operation of individual participants and/or the club as a whole. Disciplinary Action- Group: The disciplinary action of an individual can affect the disciplinary action of the club. In addition, in accordance with the State of New York s updated Rules of Student Conduct (Pursuant to Article 129-A [NYS Education Law 6430 (2)]; Student groups and organizations recognized administratively or by student government(s) and/or their officers may be charged with, and held responsible for violations of these conduct codes. Sanctions against the student organizations and it s officers may include revocation of recognition of the group, loss of permission to use University facilities and the University name as well as other appropriate sanctions. Clubs, through the actions and/or failure to act, of the group as a whole in addition to individual actions and/or failure to act, may be placed on probation or suspension by the Club Sports administration and Campus Recreational Services for the following reasons (but not be limited to): (a) Actions that violate the Rules of Student Conduct published by Binghamton University; (b) Actions that would discredit the University or the Division of Student Affairs; (c) Actions that would violate Club Sport policies and participant agreements; (d) Failure to follow state, federal laws, rules or policies. Agreement: I, (print name), agree to review and abide by all University Student Code of Conduct polices as well as follow policies as outlined by Club Sports. I will do everything in my power to ensure that neither hazing nor harassment occurs within my respective club sport. Furthermore, if I learn of any incident resembling hazing or harassment, I will immediately notify a member of the Club Sports administration. I agree to follow and abide by all club sport game policies. I understand and accept any/all immediate and future consequences deemed appropriate by the aforementioned registration policies. Signature & Date

5 CLUB SPORTS INDIVIDUAL PARTICIPANT REGISTRATION GAME & UNIVERSITY STUDENT CODE OF CONDUCT- USE OF TECHNOLOGY Game/University Code of Conduct: All club sports members are expected to demonstrate the utmost respect to game officials, coaches, and their opponents. Sportsmanship is an essential ingredient to the successful image of Binghamton University, Campus Recreation and Club Sports as a whole. Club Sport Teams, leadership and participants of said Club are a reflection of not only the club itself but also the Club Sports Program, Campus Recreational Services and Binghamton University. All club sport members are expected to review and abide by all University Student Code of Conduct Policies. Failure to demonstrate the utmost respect to game officials, coaches, opponents and/or supporters while home and/or away as well as ignoring University Student Code of Conduct Policies may jeopardize immediate and/or future individual participation as well as current and/or future club active status. Use of Technology: Inappropriate use of technology (includes but is not limited to Social Media, Individual/Group Web Pages, , Instant Messaging, Texting, ect) that reflect a poor image of the Club, Club Sports, Campus Recreation and/or Binghamton University and/or any individual associated with the aforementioned groups will result in appropriate individual and/or club discipline. a. Restrictions against inappropriate language/photographs/images apply to all electronic communications, that may include public messages/photos/images, private messages/photos/images, and material posted on club and/or individual web pages. b. Clubs and individual members of the club will not use obscene, profane, lewd, vulgar, rude, inflammatory, threatening, or disrespectful language/photos. c. Clubs and individual members of the club will not post information that could cause damage or a danger of disruption to the Club, Club Sports, Campus Recreation and/or Binghamton University or any other organization or person. d. Clubs and individual members of the club will not engage in personal attacks, including prejudicial or discriminatory attacks. e. Clubs and individual members of the club will not harass or cyber-bully another person, club, team and/or organization. f. Clubs and individual members of the club will not knowingly or recklessly post false or defamatory information about a person or organization. Agreement: I, (print name), agree to review and abide by all University Student Code of Conduct polices as well as follow policies as outlined by Club Sports. I will do everything in my power to ensure the utmost respect of and to game officials, coaches, opponents and/or supporters at home and/or away is demonstrated. If I learn and/or am involved in such instances, I will notify the club sports office. I agree to use technology appropriately as I am aware I represent myself, the club I am a current participant of, Club Sports, Campus Recreational Services and Binghamton University. I will represent the aforementioned groups in a positive manner. I understand and accept any/all immediate and future consequences deemed appropriate by the aforementioned registration policies as failure to follow said registration policies can impact my immediate and/or future status as a club participant as well as jeopardize the current and/or future active status of the club I am associated with. Signature of Agreement Date

6 CLUB SPORTS INDIVIDUAL PARTICIPANT REGISTRATION HONOR CODE REGARDING ALCOHOL/ SUBSTANCE ABUSE I, the undersigned, agree to abide by the following policy regarding the use of alcohol and illegal substances while I am representing Binghamton University and Campus Recreation as a member of a recognized club sports team. I know that the abuse of these substances can lead to poor performance, endanger my health and safety, and endanger the health and safety of other competitors in the event in which I am participating. I, therefore agree: 1. I will not use alcohol or illegal substances of any kind on any away club sports trip during the entire duration of that trip; 2. I will not use alcohol or illegal substances for a period of time up to 24 hours prior to any club sport related competition; 3. I will not use alcohol or illegal substances at the site of any club sport contest (home, away, practice) or while being transported to or from any contest in which I am a participant; 4. I understand I am always a member of the Binghamton University community, and I will conduct myself accordingly; 5. I understand that failure to abide by the above stated policies as well as current Binghamton University and Club Sport policies will result in my immediate suspension from any Binghamton University Club Sports Team until further review by the Club Sports Program at Binghamton University. 6. I understand that failure to abide by the above stated policies as well as current Binghamton University and Club Sport policies may result in immediate team/club suspension until further review by the Club Sports Program at Binghamton University. I agree to abide by the above policy as well as all policies outlined within the Binghamton University Student Handbook. Failure to sign will preclude my participation within the Club Sports Program at Binghamton University. Club Sport: Name (Please Print): Signature of Agreement: Date:

7 Club Sports Transportation Agreement and Acknowledgement (All participants must review, sign and add vehicle information when/if necessary) Participant Name (printed): Club: Vehicle Information (The information below is current, I understand I must submit updates/changes to said information immediately): Make: Model: Year: State: Plate: Driver License ID with State: Insurance Company: Insurance Policy Number: In consideration of my ability to participate in the above mentioned club, I acknowledge that I have indicated that I am willing to assist with the transportation of myself and other club members to/from practices, games, tournaments and/or special events that have been designated and approved as an official club activity from Binghamton University s Campus Recreational Services- Club Sports. In consideration of my current and/or future ability to participate in the above mentioned club as a member to which I am providing transportation, I acknowledge, appreciate, and agree that as the owner/user of said vehicle providing club transportation I understand and agree; 1. Binghamton University, Campus Recreational Services, Club Sports and the specific club I am participating in is not and will not be held liable for privately owned vehicles or damages that they may cause. 2. It is my responsibility to maintain my vehicle in accordance with State law, this also includes but is not limited to maintaining current and appropriate automotive registration, inspection and insurance. I will notify appropriate club leadership and club sports administration should there be any changes to the status of my vehicle that may affect and/or change my ability to provide transportation. 3. Any travel associated with club practice and/or approved event(s) may have unforeseeable circumstances which could result in an accident/ injury, beyond the control of Binghamton University, Campus Recreational Services, Club Sports and the specific club I am participating in. I knowingly assume as such risks. 4. The risk of injury to myself and passengers regarding club travel and transportation is significant, including the potential for permanent paralysis and death. I understand and accept full responsibility for and of all passengers in which I am providing transport. 5. I should contact my appropriate automotive insurance representatives to confirm coverage. Should there be a change to my insurance or carrier, I understand it is my responsibility to notify the appropriate club leadership and club sport administration immediately to remove myself as a means of providing transport. I will resolve said concerns with my insurance carrier and appropriate club leadership no later than forty-eight (48) hours of the designated travel date for practice and/or an event so the club can make the necessary adjustments in accordance to travel policies and procedures. 6. To contact the appropriate club sports representative with updates, additions and/or changes in circumstance regarding my vehicle insurance coverage or driving record. These include but are not limited to motor vehicle traffic violations, license suspension, license removal, insurance, new vehicle altogether. I understand it is my responsibility to contact the club sports office immediately. Failure to do so on my part may affect future participation as a club participant and/or travel designee. 7. I may be subject to a drivers license check regarding my driving record which may result in the removal of myself and vehicle as a mode of club transportation. 8. I HAVE CAREFULLY READ AND CONSIDERED THIS INFORMATION AND FULLY UNDERSTAND ITS CONTENTS. I AM AWARE THAT I AM RELEASING CERTAIN RIGHTS that I may have otherwise and enter into this contract on behalf of myself and my family in consideration of being permitted to participate in Binghamton University Campus Recreational Services, but more specifically Club Sports and the club to which I am a participant of named above. I attest all information submitted by me is true and accurate to the best of my knowledge. I fully understand submitting misrepresented information, failing to disclose significant information, emitting facts, and/or falsifying documents may result in serious personal injury, death, university judicial and/or legal action against me. Signature of Agreement and Acknowledgement Date