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Admissions & Aid
Individual Member Information Form
Individual Member Information Form
Club Sport Healthcare
Start or Join a Club
Date of Birth
Year in School
Emergency Information: Person to Notify in Case of Emergency
Emergency Contact Name
Relationship to Emergency Contact
1. Are you Covered under: University Insurance Plan
2. Are you Covered under: Personal Insurance Plan
If you answered yes to #2, list the company through which you are insured and the policy number
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
A member of
, recognized sport club at the University of Massachusetts at Lowell affirm that:
I am aware of my physical condition.
I am voluntarily participating in the aforementioned club.
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.
Please read the following section carefully. Upon completion, please sign at the bottom of the form indicating that you understand the content.
What follows is the actual Massachusetts Law prohibiting the practice of hazing. Please read carefully. As required, every student is to receive a copy of this law. An Act Prohibiting the Practice of Hazing. Chapter 269 of the General Laws as Amended January 5, 1988:
Whoever is a principal organizer or participant in the crime of hazing, as defined herein, shall be punished by a fine of not more than three thousand dollars or by imprisonment in a house of correction for not more than one year, or both such fine and imprisonment. The term "hazing" as used in this section and in sections eighteen and nineteen, shall mean any conduct or method of initiation into any student organization, whether on public or private property, which wilfully or recklessly endangers the physical or mental health of any student or other person. Such conduct shall include whipping, beating, branding, forced calisthenics, exposure to the weather, forced consumption of any food, liquor, beverage, drug or other substance, or any other brutal treatment or forced physical activity which is likely to adversely affect the physical health or safety of any such student or other person, or which subjects such student or other person to extreme mental stress, including extended deprivation of sleep or rest or extended isolation. Notwithstanding any other provisions of the section to the contrary, consent shall not be available as a defense to any prosecution under this action.
Whoever knows that another person is the victim of hazing as defined in section seventeen and in at the scene of such crime shall, to the extent that such person can do so without danger or peril to himself or others, report such crime to an appropriate law enforcement official as soon as reasonable practicable. Whoever fails to report such crime shall be punished by a fine of not more than one thousand dollars.
Each institution of secondary education and each public and private institution of post secondary education shall issue to every student group, student team or student organization which is part of such institution or is recognized by the institution to exist as an unaffiliated student group, student team or student organization, a copy of this section and sections seventeen and eighteen; provided however, that an institution's compliance with this section's requirements that an institution issue copies of this section and sections seventeen and eighteen to unaffiliated student groups, teams or organizations shall not constitute evidence of the institutions's recognition or endorsement of said unaffiliated student groups, teams or organizations shall not constitute evidence of the institutions recognition or endorsement of said unaffiliated student groups, team or organizations. Each such group, team or organization shall distribute a copy of this section and sections seventeen and eighteen to each of its members, plebes, pledges or applicants for membership. It shall be the duty of each such group, team or organization, acting through its designated officer, to deliver annually, to the institution an attested acknowledgement stating that such group, team or organization has received a copy of this section and said sections seventeen and eighteen, that each of its members, plebes, pledges, or applicants has received a copy of sections seventeen and eighteen, and that such group, team or organization understands and agrees to comply with the provisions of this section and sections seventeen and eighteen. Each institution of secondary education and each public or private institution of post secondary education shall file at least annually, a report with the regents of higher education and in the case of secondary institutions, the board of education, certifying that such institution has complied with its responsibility to inform student groups, teams or organizations and to notify each full time student enrolled by it of the provisions of this section and sections seventeen and eighteen and also certifying that said institution has adopted a disciplinary policy with regard to the organizer and participants of hazing, and that such policy has been set forth with appropriate emphasis in the student handbook or similar means of communicating the institution's policies to its students. The Board of Regents and, in the case of secondary institutions, the Board of Education shall promulgate regulations governing the content and frequency of such reports, and shall forthwith report to the attorney general any such institution which fails to make such report.
I have read and understand the Massachusetts Hazing Law
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