Healthy Hornet Registration Form
Last name, First name
Your answer
Email of Participant
Your answer
Card ID Number
Faculty/Staff: We will activate your cards so you can have access to the Recreation Center
Your answer
Gender
I am
My personal SMART goal for the challenge time period of Jan 30 through Feb 28 is:
Your answer
Please let us know if you would like a free physical fitness assessment during our "Know Your Numbers" Kickoff event on Monday, Jan 30
(Bonus points will be awarded)-Testing will include blood pressure, cardiovascular fitness, muscular fitness, flexibility and body composition testing.)
Waiver of Liability and Release Statement
Individual participants should be duly aware of the risks and hazards involved when participating in recreation and fitness activities. Participation is voluntary and this signed waiver serves to provide as an informed consent, whereby the individual signing the waiver chooses to utilize ESU facilities and/or equipment and/or participate in programs and services provided by the Recreation Services department, the Department of Health, Physical Education and Recreation, the Student Wellness Center and Human Resources. In consideration of said voluntary participation, the undersigned agrees to assume all risks of loss, damage, or injury that may be sustained while using ESU facilities and/or equipment and/or participating in programs and/or services. These injuries may range from a slight bruise or scratch to broken bones, internal injuries that could cause brain damage or paralysis, injuries to the spine that may cause quadriplegia, and other types of catastrophic injuries that may even result in death. Furthermore, the Recreation Services department, the Department of Health, Physical Education and Recreation, the Student Wellness Center and Human Resources assumes no responsibility for costs incurred with individual injury or property damage related to the use of university facilities and/or equipment and/or participation in programs and/or services. Individuals are reminded that they should review his/her own personal circumstances to determine if he/she has adequate health and accident insurance to protect against financial loss should participation result in serious injury. It is recommended that all participants have a physician’s approval before engaging in any physical activity.

As verified by my checking the liability release box above, I hereby release the State of Kansas, the Kansas Board of Regents, Emporia State University, the Recreation Services department, the Department of Health, Physical Education and Recreation, the Student Wellness Center and Human Resources and their respective employees, interns, practicum students, and volunteers from all liability based upon negligence or any other cause for any loss, damage, or injury incurred in relation to use of university facilities and/or equipment and/or through participation in any Recreation Services department programs, the Department of Health, Physical Education and Recreation, the Student Wellness Center and Human Resources activities or services.|Individual participants should be duly aware of the risks and hazards involved when participating in recreation and fitness activities. Participation is voluntary and this signed waiver serves to provide as an informed consent, whereby the individual signing the waiver chooses to utilize ESU facilities and/or equipment and/or participate in programs and services provided by the Recreation Services department, the Department of Health, Physical Education and Recreation, the Student Wellness Center and Human Resources. In consideration of said voluntary participation, the undersigned agrees to assume all risks of loss, damage, or injury that may be sustained while using ESU facilities and/or equipment and/or participating in programs and/or services. These injuries may range from a slight bruise or scratch to broken bones, internal injuries that could cause brain damage or paralysis, injuries to the spine that may cause quadriplegia, and other types of catastrophic injuries that may even result in death. Furthermore, the Recreation Services department, the Department of Health, Physical Education and Recreation, the Student Wellness Center and Human Resources assumes no responsibility for costs incurred with individual injury or property damage related to the use of university facilities and/or equipment and/or participation in programs and/or services. Individuals are reminded that they should review his/her own personal circumstances to determine if he/she has adequate health and accident insurance to protect against financial loss should participation result in serious injury. It is recommended that all participants have a physician’s approval before engaging in any physical activity.

Liability Release
I agree with the terms of the WAIVER OF LIABILITY AND RELEASE STATEMENT at the bottom of this form.
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