September 21 st , 2013
9am- 2pm
Registration Instructions
1.
Complete the registration form.
2.
Please ask the students in your class to complete the Assumption of Risk Forms.
3.
Deliver the completed registration form and completed Assumption of Risk
Forms to the Adanti Student Center, Room 212.
Instructors Name:
Instructor Email Address:
Instructor Phone Number:
____________________________
____________________________
____________________________
Class contact for the group for the day of the event (instructor or peer mentor)
____________________________ ____________
Contact Email/Cell phone ____________________________
Peer mentor: ____________________________________________________
Course Number: ____ Number of students attending: _________
Please register each class separately. If you would like to be paired with another
INQ section, please indicate which course you would like to be paired with. We will do our best to accommodate requests but cannot guarantee it. Most sites only accommodate 25-35 students.
Additional Course Number(s): ____ _________
Once the Office of Student Life received the registration form, we will send a confirmation to the instructor. Please contact the Office of Student Life at 203 392 5782 or rizzas1@southernct.edu
with any questions or if you need any assistance.
For classes without Peer Mentors, you can contact Sal Rizza, Associate Director of Student Life at rizzas1@southernct.edu
for assistance with the registration process. A member of the SCSU Service Team can be scheduled to attend your class, speak about the Day of Service, and conduct the registration process.

SOUTHERN CONNECTICUT STATE UNIVERSITY
New Haven, Connecticut 06515-1355
STATEMENT OF DUE WARNING AND ASSUMPTION OF RISK FORM
Print or Type Information
I, _____________________________________ being eighteen (18) years of age or older, voluntarily agree to participate in the following activity (please list specifics)
The Dr. Ronald D. Herron Day of Service in New Haven and Hamden (Various
Locations)
On the following date(s) September 21 st , 2013
With the following class/group/organization:
I am aware of the inherent and/or latent danger (including but not limited to: risk of serious injury, the hazards of travel, accident or illness, or acts of God) of participating in such an activity.
I am aware that I should (if appropriate) have a medical exam prior to participating in this activity to ensure that I am in good physical health. I am aware that I should see that I am properly covered by adequate accident and/or medical insurance. If I am not, I agree to obtain sufficient liability/accident/health/travel insurance, at my own expense, to insure me against any loss occasioned by this activity.
I am also aware and have been advised that the University and/or its personnel will provide minimal or no supervision during this activity.
Knowing this, I assume all risks that may arise from or in connection with this activity. In addition, I do hereby agree and warrant to release and hold harmless the State of Connecticut, Board of Trustees of the Connecticut State University and/or Southern Connecticut State University, its agents and employees, from any and all liability, claims, demands, actions and causes of action whatsoever, arising out of or related to any loss, damage or injury resulting from my voluntary participation in this activity.
Individual's Name
Student ID # Local Telephone
Local Address
_________
Emergency contact info:
Signature
Name
Phone
Day
Date
Night
Forms must be submitted to the Office of Student Life,
Michael J. Adanti Student Center, Room 213, prior to the activity taking place.