You must have JavaScript enabled to use this form. Contact Information First Name Last Name Email Phone Address City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle EastArmed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederate States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Emergency Contact First Name Last Name Relation Phone Medical Release and Waiver I fully understand that there are risks involved in my participation and usage of the ETBU Dean Healthplex and athletic facilities. I voluntarily desire to participate in activities; and that I am duly aware of the risks and hazards that may arise through participation in activity. In consideration for my participation, the undersigned hereby voluntarily assumes all risks of accident or damage to person or property and risks of liability. The undersigned does further agree to indemnify and hold harmless East Texas Baptist University and its regents, administrators, employees or agents from any and all claims or demands for loss, cost, injury, or damage whatsoever associated with participating in any and all activities or from my improper use of equipment, technique, or failure to follow safety rules and instructions. The undersigned, by signing this release, hereby certifies that the undersigned has read and fully understands the conditions herein provided and that he/she signs this agreement voluntarily and without reliance upon any promise or representation which is not contained in the agreement. I give authorization to East Texas Baptist University or designated entity to evaluate me and treat any injuries that occur during said activity. This includes immediate first aid and treatment, referral to hospital or physician consultation, and/or emergency services. Signature Sign above Date