ETSU CAMPUS RECREATION
BASLER CENTER PHYSICAL ACTIVITY
American Red Cross First Aid/CPR/AED Class
Today’s Date:______
Participants name:______Age:______
ID#:______Email:______
Cell Phone:______Work or Home Phone: ______
Address:______
City:______State:_____Zip:______
ETSU Department or if student year in school:______
How did you hear about this certification:______
Please choose one:
ETSU Patron- CPR/AED and First Aid, Sat. Feb. 18th: 9am-3pm: $30
Non-ETSU Patron- CPR/AED and First Aid, Sat.Feb. 18th: 9am-3pm: $50
*Maximum of 20 people per class; Minimum of 4 people per class.
For more info visit:
FOR OFFICE USE ONLY
Date:______Time:______
Staff name: ______
East Tennessee State University
Department of Campus Recreation - Basler Center for Physical Activity (BCPA)*
Non-Credit Classes Informed Consent/Assumption of Liability/Refund Policy
Informed Consent:
I would like to participate in an ETSU Campus Recreation Non-credit class. I am aware that there are risks and hazards which may arise through participation in this activity. These risks include but not limited to: drowning, near drowning, paralyzing injuries, brain injuries, and slipping on the pool deck. These activities may be of a hazardous nature and/or may include activities such as swimming, diving, a variety of strenuous exercises and physical activities. With the full understanding of the facts, I state that to the best of my knowledge, that I (or my son/daughter taking the class) has no medical, physical, or emotional health conditions, which would prevent his/her participation in the ETSU Campus Recreation program.
Assumption of Liability (participants 18 years old and up):
I willingly and knowingly assume for myself, my heirs, family members, executive administrators and assigns all risk of physical and emotional injury which may occur during or after participating in any aspect of the program and hereby agree to hold the State of Tennessee, The Tennessee Board of Regents, East Tennessee State University, its employees, instructors, facilitators, agents and volunteers harmless for any liability arising out of my participation in the program. Should ETSU or anyone acting on behalf be required to incur attorneys fees and costs to enforce this agreement, I agree to indemnify (to assume the responsibility for payment of damages to someone else) and hold ETSU harmless for all such fees and costs. This release does not, however, apply to physical injury or emotional harm caused by negligence or willful misconduct of ETSU, its employees, instructors, facilitators, and agents.
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Participants printed name
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Participants signature (do not sign if under 18)Date
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***FOR PARTICIPANTS UNDER THE AGE OF 18 ***
The below named participant, a minor for whom I am the parent or legal guardian, has my permission to participate in the ETSU Campus Recreation Program. I have read the informed consent and on behalf of myself and my minor daughter/son, I release the State of Tennessee, The Tennessee Board of Regents, East Tennessee State University, its employees, instructors, facilitators, agents and volunteers from any and all liability in connection with my minor daughter/son’s participation in this activity. I understand that this release covers any and all claims again East Tennessee State University (or any of those mentioned above), including claims of negligence. I agree that this release binds me, my family, estate, and/or heirs.
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Print participant’s/child’s name Parent/Guardian printed name
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Parent/Guardian signature Date
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Refund Policy – Read and initial below:
- There are no refunds if you are not able to complete or pass any part of the class or certification.
- There are no refunds if you withdrawal from the class 48 hours prior to the first date of the class.
- Full refunds are granted if you withdrawal from the class 7 days prior to the first date of the class.
- Partial refunds (50%) are granted if you withdrawal from the class 6 days to 48 hours prior to the
first date of the class. _____Initial