PHED Activity Class Information Sheet & Waiver
Last Name: _______________ First: _______________
Class/CRN #:_______________
HCC ID #____________
Phone numbers: home _______________ & cell _______________
*Emails will be sent to your HCC email address.
*Emergency Contact:
Name: _______________________________
Relationship: ___________________
Phone Number(s): ______________________ & ______________________
* By providing this information, you are granting permission for this person to be contacted
in case of an emergency.
Is there any other information you would like for me to know about you (that may affect your
performance/well-being in this class; including allergies/medications)?
Waiver
I _________________________________ (print name) understand that activity classes include physical
movements that may include, jumping, running/jogging, aerobic dance, stretching and other forms of
physical activity, the risk of injury, even serious or disabling, is always present and cannot be entirely
eliminated. If I experience any pain or discomfort, I will listen to my body, and ask for support from the
instructor.
Activity classes are not recommended and are not safe under certain medical conditions. I affirm that I
along with my instructor am responsible to decide whether or not I am healthy enough to participate in
activity classes. I hereby agree to irrevocably release and waive any claims that I have now or hereafter
may have against Houston Community College and/or my instructor.
I have spoken to the instructor regarding the nature, content, and requirements of this class. I have also
had the opportunity to ask the instructor any questions about my participation in this class. I have
indicated above any health problems that would limit my participation in this class.
I have read the syllabus and plan to continue enrollment in this course. I understand and accept the
purpose, requirements, objectives and the grading criteria of this course as stated in the course syllabus
as well as all of the policies and procedures.
_____________________________________
Student Signature
___________________________
Date