Assumption of Risk, Waiver of
Liability and Release Agreement
By my signature below, I acknowledge that I am aware of, appreciate the character of, and voluntarily assume the risks
involved in participating in all activities associated and available at the South Dakota State University Wellness Center.
Under certain circumstances, adopting an exercise program has some inherent risks. A medical examination is
encouraged prior to starting an exercise program.
By my signature below, on behalf of myself, my heirs, next of kin, successors in interest, assigns, personal
representatives, and agents, I hereby:
1. Waive any claim or cause of action against and release from liability the State of South Dakota, its officers, employees,
and agents for any liability for injuries to my person or property resulting from my participation in the activity listed
above;
2. Agree to indemnify and hold harmless the State of South Dakota, its officers, employees, and agents for any claims,
causes of action, or liability to any other person arising from my participation in the activity listed above;
3. Consent to receive any medical treatment deemed advisable in the event of injury, accident or illness during these
activities; and
4. Acknowledge that a participant under 18 years of age signing below as a minor child, a signature is required by the
parent or legal guardian of the minor child to participate.
5. Are you required by law to register as a sex offender in this state or any other state? ___ No ___ Yes
6. Authorize SDSU to photograph me and or my property and authorize SDSU the absolute right and unrestricted
permission to publish and/or use such photographs for use in any of its publications and/or promotional materials.
I HAVE READ THIS ASSUMPTION OF RISK, WAIVER OF LIABILITY AND RELEASE AGREEMENT. I CONSENT TO MEDICAL
TREATMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING
IT, AND HAVE SIGNED IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT, ASSURANCE, OR GUARANTEE BEING
MADE TO ME AND INTEND MY SIGNATURE TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE
GREATEST EXTENT ALLOWED BY LAW.
The SDSU Wellness Center reserves the right to refuse membership or terminate membership at its discretion in
instances where the Operation Manual is violated. A copy of the Operation Manual is available at the Welcome Desk or
on the web at http://www.sdstate.edu/wellness-center/.
----------------------------------------------------------------------------------------------------------------------------------------------Participant Printed Name __________________________________________ Date of Birth __________
I HAVE READ THIS RELEASE
Signature _______________________________________________________
Date_________________
Address_________________________________ City____________________
State__________
Email:__________________________________________________ Phone:__________________________
----------------------------------------------------------------------------------------------------------------------------------------------Minors: under 18 years of age
Parent or Legal Guardian Printed Name _______________________________
Relationship ___________
I HAVE READ THIS RELEASE
Parent or Legal Guardian Signature ___________________________________
Date__________________
(Revised 8.2014) Printed on recycled paper.
Member
Student
Day Pass