Please fill in your name (required) :
Waiver and Membership Form for the Lynchburg College Club (required) :
Classification (required) :
  •  Fr
  •  So
  •  Jr
  •  Sr
  •  Grad Student
  •  Faculty/Staff
Local Address (required) :

Local Telephone (required) :
Permanent Address :
Phone :
Guardian (required) :
Over the age of 18 (required) :
  •  Yes
  •  No

If you are not over the age of 18, you must also fill out the Minor Informed Consent Sheet. 


Notify in case of emergency:


Name (required) :
Relationship (required) :
Phone (required) :
Do you have Student accident and illness insurance? (required) :
  •  Yes
  •  No
Are you covered by your own or parents’ hospitalization plan? (required) :
  •  Yes
  •  No

I state that my participation in the Club Sport is entirely voluntary. In registering as a participant in Club Sports, I voluntarily agree to assume all risks in participating in Club Sports activities.  These risks include but are not limited to pulled muscles, broken bones, concussion, knee and joint injury or death.  I agree not to sue Lynchburg College, it’s officers, employers, agents, and assistants for any damage, demands, and actions whatsoever, whether such damage be known or unknown.  This also includes attorney’s fees in any matter resulting from my participation in Lynchburg College’s Club Sports and recreational sport programs including, but not limited to, practice, game participation, organization and operation of leagues, supervision of participants, and/or maintenance and operation of playing fields and premises.

In registering as a participant in Club Sports, I understand that my name and picture will be used to ONLY promote the Lynchburg College Club Sports Program and events and activities.  I give Lynchburg College and the Club Sports Program my permission to use my name and picture when promoting its program.

I understand the risks involved in this activity, and I am physically fit and adequately informed to participate.  I agree that I am personally responsible for all risks of injury of damage to person or property in any way arising out of my participation in this activity.

Signture (required) :
Date (required) :
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