PROGRAMPARTICIPATIONREGISTRATIONFORM-MINORS
Today’sDate:______________________
Name:______________________________________________________________Gender:M_____F_____
StreetAddress:_____________________________________________________________________________
City/State/Zip:______________________________________________________________________________
DateofBirth:________________________ e-MailAddress:_________________________________________
HomePhone:_________________________Wouldyouliketoreceiveouremailalerts?___Yes____No
CellPhone:___________________________Wouldyouliketoreceivetextalerts?
____Yes____No
CarMake/Model:_______________________________________LicensePlate#:_______________________
EMERGENCYCONTACT
Contact’sName:________________________________________ HomePhone:_________________________
RelationshiptoSelf:_____________________________________ Work/Alt.Phone:_____________________
MEDICALINFORMATION
Doanyoftheseconditionsapplytoyou?
Vomiting(emesis)
YES
NO Contraindicated
OpenWoundsornon-healingulcers
Contraindicated
BowelIncontinence/Diarrhea
Contraindicated
ContagiousSkinConditions
Contraindicated
HighFever
Contraindicated
InfectiousDiseases
Contraindicated
EarorEyeInfections
Contraindicated
UrinaryInfections
Contraindicated
PerforatedEardrum
Contraindicated
ChlorineAllergy
Contraindicated
SeizureDisorder(notcontrolledbymedication)
Requiresphysicianapproval
Pregnancy
Requiresphysicianapproval
RecentChemo/RadiationTherapy
Requiresphysicianapproval
HeartDisease(notcontrolledbymedication)
Requiresphysicianapproval
BladderIncontinence
RequiresuseofREUSABLEswimretainer
AnyOpenCatheter/Ostomy/Trach/etc.
Checkwithyourphysicianforproper
infectioncontrol
OfficeUseOnly:MemberID______ParkingPermitID_____
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AGREEMENTANDRELEASEFROMLIABILITY
Byinitialinginthespaceprovidedandsigningbelow,IamacknowledgingthatIhavereadandunderstandthe
following:
PATRONAGREEMENTOFCODEOFCONDUCTANDPOLICIESANDPROCEDURES
_____ I have read and understand the attached Timpany Center Code of Conduct and Policies and
Procedures.IunderstandandagreethattheuseoftheTimpanyCenterisaprivilegeandthatImust
comply with the Code of Conduct and Policies and Procedures in order to use the facility and
participateinitisprograms.Iunderstandandagreethatviolationsofthiscodeandthesepoliciesmay
resultintherevocationofmyrighttoaccessandparticipateintheTimpanyCenterprogramsandthe
forfeitureofanymembership,class,orotherfeesthathavebeenpaid.
VOLUNTARYPARTICIPATION
_____ IherebyacknowledgethatIhavevoluntarilyappliedtousetheTimpanyCenterlocatedat730Empey
Way,SanJose,California95128,toparticipateinvarioussportingactivitiesinthefacility,including,but
notlimitedto,activitiesintheswimmingpoolsandgymnasium.
ASSUMPTIONOFRISK
_____ I am aware that aquatic-based and/or land-based recreational activities can be hazardous. I am
voluntarily participating in these activities with knowledge of the danger involved. I hereby agree to
acceptanyandallrisksofinjuryordeath.
LIABILITYRELEASE
_____ As consideration for being permitted by San Jose State University (SJSU) or one of its affiliated
organizationstoparticipateintheseactivitiesandusetheirfacilities,IherebyagreethatIand/ormy
assignees,heirsdistributes,guardians,andlegalrepresentativeswillnotmakeaclaimagainst,sue,or
attachthepropertyofSJSUand/oranyofitscurrentandformeremployees,agents,orcontractorsor
any of its affiliated organizations as a result of my access to the Timpany Center and/or my
participation in aquatic-based and/or land-based recreational activities at the Timpany Center. I
herebyreleaseSJSUand/oranyofitscurrentandformeremployees,agents,orcontractorsand/orany
of its affiliated organizations from all actions, claims, or demands that I, my assignees, distributes,
guardians,andlegalrepresentativesnowhaveormayhereafterhaveforinjuryordamage,howsoever
caused, resulting from my access to and/or participation in aquatic-based and/or land-based
recreationalactivities.
MEDIARELEASE
_____ IherebycertifythatIamanadultovertheageofeighteenyearsandIherebyconsentthatanyfilm,
photographs, videotapes, and/or sound recordings made of me by Timpany Center may be used by
SJSU and/or its affiliates, and those acting with its permission, for the purpose of illustrations,
publications,orbroadcastsinconnectionwithpromotiontheworkofandfortheTimpanyCenter.
COMPLETIONOFALLPAPERWORK
_____ IagreethatIwillcompleteanyotherpaperworknecessarytocompletetheparticipantinquiryprocess.
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KNOWINGANDVOLUNTARYEXECUTION
Ihavecarefullyreadthisagreementandfullyunderstanditscontents.Iamawarethatthisisareleaseof
liabilityandacontractbetweenmyselfandtheTimpanyCenter,theSanJoseStateResearchFoundation,San
JoseStateUniversityand/oritsaffiliatedorganizations,andSantaClaraCounty,andherebysignitofmyown
freewill.Iunderstandthat,ifIdonotsignthisAgreement,Iwillnotbegrantedaccesstothefacilityandwill
notbeallowedtoparticipateinitsprograms.
____________________________________________________DATE:___________________
===================================================================================
IfParticipantisnot18yearsofageorolder,custodialparent’sorlegalguardian’ssignatureauthorization
mustbeobtained:
I, _____________________, certify that I am a custodial parent or legal guardian of the above named
participant.Ihavereadandagreetotheprovisionsstatedabovefortheparticipant,andconsenttohis/her
access to and/or participation in the various sporting activities in the Timpany Center, including, but not
limitedto,activitiesintheswimmingpoolsandgymnasium.
IacknowledgethatIhavespecificallyreadandagree,onbehalfoftheParticipant,aminor,andmyself,tobe
boundbytheterms,conditions,andpoliciesinthisAgreementandReleaseFromLiability.
KNOWINGANDVOLUNTARYEXECUTION
Ihavecarefullyreadthisagreementandfullyunderstanditscontents.Iamawarethatthisisareleaseof
liabilityandacontractbetweenmyselfandtheTimpanyCenter,theSanJoseStateResearchFoundation,San
JoseStateUniversityand/oritsaffiliatedorganizations,andSantaClaraCounty,andherebysignitofmyown
freewill.Iunderstandthat,ifIdonotsignthisAgreement,Iwillnotbegrantedaccesstothefacilityandwill
notbeallowedtoparticipateinitsprograms.
____________________________________________________DATE:___________________
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