Whitworth University Release and Informed Consent Form

We look forward to hosting you at Whitworth University! Campus visits are an excellent opportunity for you to learn more about all aspects of academic and student life at Whitworth. Note: submission of this form is required for all campus visitors seeking to stay overnight on campus.

Email Address

First Name

Preferred Name

Last Name

Birthdate

Name of visit event:

Overnight Stay

Release Form and Informed Consent

Whitworth requires guests, like current students, to take responsibility for their actions while on campus. Please review these expectations before signing the agreement in the space below.

I am aware that although Whitworth University has agreed to host me/my dependent overnight, neither the Office of Admissions nor any other office or personnel of Whitworth University will be supervising visitors at all times during their stay on campus.

I am aware that participants in on-campus visit programs are required to abide by Washington state law and the Student Behavior Policy outlined in the Whitworth Student Handbook. I understand that current and visiting students are expected to abide by the following three main rules of campus:

There is to be no on-campus possession, consumption, distribution of alcohol, marijuana, illegal drugs or mood-altering substances, or controlled medication without a prescription.
There is to be no cohabitation on campus. We understand the term “cohabitation" to include sexual contact outside marriage, and/or the spending of a night together by two people engaged in a romantic or sexual relationship.
There is to be no violent or destructive behavior or other conduct that threatens or endangers the safety or emotional well-being of any person on campus.

I understand that any inappropriate or illegal behavior on my/my dependent’s part during my/my dependent’s campus visit may result in termination of my/my dependent’s visit and loss of consideration for enrollment at Whitworth University. Further, I may not be permitted to participate in any visit activities after the violation occurs and will be sent home at my/my dependent’s expense as soon as travel arrangements can be made.

I understand that my host is a student volunteer and I agree to respect their personal property and time, including time for sleep, study and classes.

I voluntarily accept full responsibility for any loss, property damage, physical or mental injury, death, and all other damages that may be sustained by me or my dependent, including without limitation, loss or damage to property owned by me/my dependent or in my/my dependent’s possession, lost wages, loss of earning capacity, and emotional harm, as a result of my visit to Whitworth University.

I further assume full responsibility for all such damages caused to others by my or my dependent’s conduct. In consideration of Whitworth University permitting me or my dependent to participate in activities on campus, I hereby voluntarily consent to and accept all risks associated with participation. I agree to indemnify, defend, save, hold harmless, discharge and release Whitworth University, their agents, employees and officers (“Releasees”) from any and all liability, claims, causes of action or demands of any kind and nature whatsoever, including attorney’s fees incurred by Releasees, that may arise from Releasees’ negligent conduct or from my own negligent or intentional conduct or that of my dependent, in connection with my or my dependent’s participation in any activities related to the visit.

Whitworth University does not diagnose or treat medical problems. The advice of a qualified health care professional should be sought for medical issues or for guidance on participation in any on-campus activity.

I certify that I have read and understood the contents of this release, that all of my above information is correct and that it is my intention, by e-signing the release, that the same be binding not only for me, but upon my heirs, administrators, executors, successors, and assigns regarding Whitworth University.*

Note: If participant is under 18 years of age, a parent/legal guardian must also e-sign and accept responsibility for the participant’s actions and his/her compliance with the terms of this Release and Informed Consent Form.

Is the prospective student over 18 years of age?*

Note: If participant is under 18 years of age, a parent/legal guardian must also e-sign and accept responsibility for the participant’s actions and his/her compliance with the terms of this Release and Informed Consent Form.

Is the prospective student over 18 years of age?*

Yes

No

I certify that I have read and understood the contents of this release, that all of my above information is correct and that it is my intention, by e-signing the release, that the same be binding not only for me, but upon my heirs, administrators, executors, successors, and assigns regarding Whitworth University.*

*Name of Parent/Guardian:

Use of the Whitworth University Recreation Center

Release Form and Informed Consent

The University Recreation Center has been designed to provide the optimum level of beneficial exercise and enjoyment without compromising the health and safety of its participants; yet because of the nature of the program and the equipment, which is an integral part of many activities, there is an inherent risk of injury. The University Recreation Center enlists your assistance in assuring that the facilities and the equipment are utilized in a proper manner so that the inherent risks are minimized by thoughtful and cautious use of the equipment and facilities.

The participant further acknowledges and accepts the rules and procedures concerning the use of the equipment and facilities of The University Recreation Center.

I hereby certify that, with or without accommodation, I am, and/or my dependent is, in good health and I know of no medical reason why I am not, or my dependent is not, able to make full use of the University Recreation Center. I hereby consent to first aid, emergency medical care, and admission to an accredited hospital when necessary for executing such care, for treatment of injuries that I/my dependent may sustain while participating in any activity associated with Whitworth University. I understand that I am responsible for all medical expenses.*

The University Recreation Center recommends that all participants undergo a complete physical examination, administered by a physician prior to using the facility.

Note: If participant is under 18 years of age, a parent/legal guardian must also sign and accept responsibility for the participant’s actions and his/her compliance with the terms of this Acknowledgment of Risk and Waiver of Liability. Individuals aged 14-17 must be accompanied by an adult when using the facility. Children under the age of 14 are not allowed to use the facility unless associated with a University Recreation Center sponsored activity.

PAR-Q & YOU

(A Questionnaire for People Aged 14 to 69)

Regular physical activity is fun and healthy. Being physically active is very safe for most people. However, some people should check with their doctor before they start to be more physically active.

If you are planning to become more physically active than you are now, start by answering seven questions in the box below. If you are below the age of 16 or over the age of 69 you should consider checking with your doctor before increasing your activity level regardless of your responses to the PAR-Q test.

Common sense is your best guide when you answer these questions. Please read the questions carefully and answer each one honestly; check Yes or No.

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?*

Yes

No

Do you feel pain in your chest when you do physical activity?*

Yes

No

In the past month, have you had chest pain when you were not doing physical activity?*

Yes

No

Do you lose your balance because of dizziness or do you ever lose consciousness?*

Yes

No

Do you have a bone or joint problem that could be made worse by a change in your physical activity?*

Yes

No

Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?*

Yes

No

Do you know of any other reason why you should not do physical activity? (i.e. pregnancy, asthma, etc.)*

Yes

No

If you answered YES to one or more questions:

Talk with your doctor BEFORE becoming more physically active or BEFORE you have a fitness appraisal. Tell your doctor about the PAR-Q and to which questions you answered YES.

You may be able to do any activity you want--as long as you start slowly and build up gradually. Or, you may need to restrict your activities to those which are safe for you. Talk with your doctor about the kinds of activities you wish to participate in and follow his/her advice.
Find out which community programs are safe and helpful for you.

If you answered NO to all questions:

You can be reasonably sure that you can:

Start becoming more physically active; begin slowly and build up gradually. This is the safest and easiest way to go.
Take part in a fitness appraisal; this is an excellent way to determine your basic fitness so that you can plan the best way for you to live actively.

DELAY BECOMING MORE ACTIVE:

If you are not feeling well because of a temporary illness such as a cold or a fever. Wait until you feel better; or
If you are or may be pregnant. Talk to your doctor before you start becoming more active.

Please note: If your health changes so that you then answer YES to any of the above questions, tell your fitness or health professional. Ask your doctor whether you should change your physical activity plan.

Signature of Student Visitor:

Signature of Parent/Guardian: