Insurance

Are you covered under:   1. University Insurance Plan? Y N    

                                           2.  Personal Insurance Plan? Y  N    

 If you answered yes to #2, list the company through which you are insured                          

                                                                                                   Policy #

 Medical History

List any operations, serious illness or hospitalizations and dates of each:

Have you ever been restricted from athletic/ recreational participation due to health problems? If yes, please list reason and date.

Consent- Fill all categories

 I,  , a member of the  , a recognized sport club at the University of Massachusetts at Lowell affirm that:

1.                  I am aware of my physical condition.

2.                  I am voluntarily participating in the aforementioned club.

3.                  I am aware that such participation may result in possible injury as a result of the nature of the sport and that I am assuming any risk that may be involved in the sport.

I agree to indemnify and hold harmless the Commonwealth, the University of Massachusetts, its Trustees, officers, agents and employees said sport club, or any members of said sport club from and against any and all claims, liability, losses, third party claims, damages, costs, or expenses (including attorneys’ fees),  from any responsibility or liability in case of personal injury sustained by me or damage to property of others caused by me during or because of participation in the activities of said sport club.

   Signature     Date