WASHINGTON STATE UNIVERSITY- UNIVERSITY RECREATION
ASSUMPTION OF RISK AND RELEASE OF LIABILITY
PLEASE READ BEFORE SIGNING!
ASSUMPTION OF RISK AND RELEASE AND WARNING!

In consideration for being allowed to participate in the Sport Club Federation as a participant in the
Sport Club mentioned above, and in all activities of the above named club on or off the WSU campus, I voluntarily agree to assume all risks involved in participating in and traveling to and from any or all activities of the club. I understand that direct supervision by Washington State University staff may not be provided and by participating in any or all club activities, I expose myself to the risk of injuries including but not limited to temporary or permanent muscle soreness, sprains, strains, cuts, abrasions, bruises, ligament and/or cartilage damage, head, neck or spinal injuries, loss of use of arms and/or legs, eye damage, disfigurement, drowning or death. I also recognize that there are both foreseeable and unforeseeable risks of injury or death that may occur as a result of my participation in any or all activities of the above named club that cannot be specifically listed. Further, I recognize that the actions of other people either affiliated or not affiliated with WSU or the above named club may cause harm or loss to my person or property.
Release of Liability
I release the State of Washington, the Regents of Washington State University, Washington State University, the University Recreation Department, and the employees, agents or representatives of Washington State University (hereafter referred to as the UNIVERSITY GROUP) from any and all liability, claims, costs, expenses, injuries or losses including those resulting from acts of negligence by the UNIVERSITY GROUP that I may otherwise sustain as a result of my participation in any or all of the activities, including travel to and from activities in a private or public vehicle, of the above named club. I also release the UNIVERSITY GROUP from loss or damage to my person or property caused by other people either affiliated or not affiliated with WSU or the above named club. If any part or portion of this Assumption of Risk and Release of Liability is determined to be invalid or unenforceable, the remaining parts or portions shall be enforceable.

Reporting Injuries/Illnesses

I agree to report any injuries/illnesses in a timely manner to University Recreation, a Certified Athletic Trainer or a Physician that have occurred while participating in Sport Clubs at Washington State University or that may be pre-existing. By doing this I will also comply with the treatment plan that is set forth by my physician. In cases of serious injury or medical conditions (i.e. concussions, sickle cell trait, diabetes, or other medical conditions), I understand that these conditions can result in serious bodily harm, side effects, or even death. I agree to be truthful and honest with my physician on any signs or symptoms that I am experiencing as a result of these injuries/illnesses.

Medical Treatment Authorization

I hereby authorize and give consent to the University Recreation Athletic Trainer and Washington State University Health and Wellness Services, or any licensed physicians, to perform or administer any reasonably necessary medical or surgical treatment. I also give permission to administer whatever anesthetic may be necessary or advisable during medical or surgical procedures. This authorization is intended to cover emergency treatment, immunizations, injections, and minor medical procedures. I authorize the University Recreation Athletic Trainer to provide Washington State University Health and Wellness Services any information requested, and authorize Washington State University Health and Wellness Services to provide the University Recreation Athletic Trainer any information requested concerning my health and athletic status.
In the event major surgery is necessary, the University Recreation Athletic Trainer, Washington State University Health and Wellness Services or licensed physicians are not excused from attempting to contact my parent(s)/legal guardian by phone or mail before relying upon this authorization. This authorization does not entitle a licensed physician to render any medical or surgical treatment without my personal consent, unless I am unable to give consent. I understand and agree that the University Recreation Athletic Trainer may use or disclose protected health information for the purpose of treatment, billing and insurance, payment, and healthcare operations.

Disclosure of Protected Health Information Authorization

I understand my injury/illness health information is protected by federal regulations under either the Health Information Portability and Accountability Act (HIPAA) or the Family Education Rights and Privacy Act (FERPA) of 1974 (The Buckley Amendment) and RCW 70.02 (Washington Health Care and Access Disclosure Statute. In accordance with the confidentiality of students’ individual educational records (FERPA), the University Recreation Athletic Training Staff will not release information to anyone outside of the following mentioned parties unless specifically designated.
 I authorize the University Recreation Athletic Trainer to speak in their sole discretion with University Recreation staff and Sport Club coaches about medical injuries, illnesses, treatment and rehabilitation that may affect my athletic performance.
 I give permission to release medical information when necessary as it relates to participation in my sport to other University Recreation Staff including administrators, personal training staff, and your parent/guardian.
This does not authorize the release of any medical information regarding an injury/illness/medical condition not affecting my athletic performance. A separate written release will be needed for discussion of any drug or alcohol abuse and treatment, or sexually transmitted diseases including HIV infection or AIDS. I understand that I may specifically request, in writing, that certain medical information not be released to the above noted persons on an incident specific basis.

By my signature below, I certify that I have carefully read this document and that I am fully informed about the RISKS associated with this activity. I am satisfied that I can safely participate in this sport. I understand this document is a contract with WSU. I or my parents/legal guardians (if I am under the age of eighteen) sign this document freely and voluntarily.