Membership Registration form

Step 1 of 7

Please note
This form is only for students who are 18 years of age and older. If you are under-aged, please visit the MAC for the paper version of the forms in order to gather the necessary parental consent signatures.
I am:*
- a student
- faculty
- staff
Student information
Name*
Address*
Street Address Address Line 2 City State ZIP Code
Email*
Enter Email Confirm Email
Main phone*
Cell phone*
Gender*
Age*
Date of birth*
Height*
Weight*
Emergency contact
Emergency contact person*
Relationship*
Telephone number*
Additional Information

Release and Healthcare Verification
I, the undersigned, agree to indemnify and hold harmless, Southern Arkansas University, and employees from any claims, damages and actions of any kind or nature, whether at law or in equity, arising from my participation in the Southern Arkansas University Mulerider Activity Center, provided that such liability is not attributable to the sole negligence of the University. I realize that my participation in this activity involves risk of injury, including but not limited to tendonitis, strains, sprains, bursitis, fractures, delayed muscle soreness, contusions, abrasions, serious eye damage and even the possibility of death. Also, I recognize that there are many other risks of injury including serious and disabling injuries which may arise due to my participation in this activity and that it is not possible to specifically list each and every individual injury risk. By signing this form I desire, consent and voluntarily choose to take part in all such activities. Knowing the material risks and appreciating, knowing and reasonably anticipating that other injuries and death is a possibility, I assume all the risks normally incident to the nature of the activities and agree that the University or any of its employees conducting such activities will not be responsible for any damages or injuries resulting to me. Furthermore, I also confirm that I have appropriate healthcare insurance for this activity or if not, that I will not rely upon the University for medical expenses. Also, I understand that any injury incurred and the resulting medical expense from that injury will be my responsibility and the University will not be responsible for any related expenses.
I acknowledge the release and healthcare verification listed above, and understand that by submitting the form I am agreeing to its terms.*
- I understand and agree
I hereby give express written permission for my photograph to be used in the advertising and promotion of Southern Arkansas University, Magnolia, Arkansas. This includes printed as well as electronic publications (web pages).
I understand and agree to the terms of the photo release.*
- Yes

Agreement and Release of Liability Form
1. In consideration of gaining membership or being allowed to participate in the activities and programs of the Mulerider Activity Center and to use its facilities, equipment, and machinery, I do hereby waive, release and forever discharge Southern Arkansas University and it officers, agents, employee, representatives, executors, and all other persons from any and all responsibilities or liability for injuries or damages resulting from my participation in all activities or my use of equipment or machinery in the above-mentioned facilities or arising out of my participation in any activities at said facility. I do also hereby release all of those mentioned and any others acting upon their behalf from any responsibility or liability for any injury or damage to myself, including those caused by the negligent act or omission of any of those mentioned or others acting on their behalf or in any way arising out of or connected with my participation in any activities of the Mulerider Activity Center or the use of any equipment at the Mulerider Activity Center.
2. I understand and am aware that strength, feasibility, and aerobic exercise, including the use of equipment, is a potentially hazardous activity. I also understand that fitness activities involve a risk of injury and even death and I am voluntarily participating in these activities in these activities and using equipment and machinery with knowledge of the dangers involved. I hereby agree to expressly assume and accept any and all risks of injury or death.
3. I do hereby further declare myself to by physically sound and suffering from no condition, impairment, disease, infirmity, or other illness that would prevent my participation in any of the activities and programs of the Mulerider Activity Center or use of equipment or machinery except as hereinafter stated. I do hereby acknowledge that I have been informed of the need for a physician’s approval for my participation in an exercise/fitness activity or in the use of exercise equipment and machinery. I also acknowledge that it has been recommended that I have a yearly or more frequent physical examination and consultation with the physician as to physical activity, exercise, and use of exercise and training equipment so that I might have recommendations concerning these fitness activities and equipment use. I acknowledge that I have either had a physical examination and have been given a physician’s permission to participate, or that I have decided to participate in activity and/or use of equipment and machinery without the approval of my physician and do hereby assume all responsibility for my participation and activities, and utilization of equipment and machinery in my activities.
By submitting this form I am agreeing to the terms outlined in the "Agreement and Release of Liability Form", as well as all the other releases and signatures submitted throughout the form.*
- I understand and agree.

	Yes	No
Has your physician ever told you that you have a heart condition?
Do you experience pain in your chest when you are physically active?
In the past month, have you experienced chest pain when not performing physical activity?
Do you lose balance because of dizziness or do you ever lose consciousness?
Do you have a bone or joint problem that could be aggravated by a change in your level of physical activity?
Is your physician currently prescribing medication for your blood pressure or heart condition?
Do you know of any other reason why you should not participate in a program of physical activity?

	Yes	No
Have you ever experienced a stroke?
Do you have diabetes?
Do you have asthma or another respiratory condition that causes difficulty with breathing?
Do you have orthopedic conditions that would restrict you in performing physical activity?
Have you ever been told by a physician that you have high blood pressure?
Have you ever been told by a physician that you have elevated blood lipids(cholesterol)
Do you currently smoke?
Have you experienced within the past 6 months back pain or discomfort that prevented you from carrying out normal daily activities?
Are you pregnant?
Do you currently exercise less than one hour per week?
Are you currently taking any medications that might impact your ability to safely perform physical activity?

	Yes	No
Do you have a heart condition?
Have you ever experienced a stroke?
Do you have epilepsy?
Are you pregnant?
Do you have diabetes?
Do you have emphysema?
Do you feel pain in your chest when you engage in physical activity?
Do you have chronic bronchitis?
In the past month, have you had chest pain when you were not doing physical activity?
Do you ever lose consciousness or do you ever lose control of your balance due to chronic dizziness?
Are you currently being treated for a bone or joint problem that restricts you from engaging in physical activity?
Has a physician ever told you or are you aware that you have high blood pressure?
Has anyone in your immediate family(parent/brother/sister) had a heart attack, stroke or cardiovascular disease before age 55?
Has a physician ever told you or are you aware that you have high cholesterol level?
Do you currently smoke?
Are you a male over 44 years of age?
Are you a female over 54 years of age?
Are you currently exercising LESS than 1 hour per week? If you answered no, Please list you activities.
Are you currently taking any medication?

Step 1 of 7

Please note

Student information

Emergency contact

Health questionnaire

Health history

Health/fitness pre-participation screening questionnaire for students

Mulerider Activity Center

Release and Healthcare Verification

Agreement and Release of Liability Form

Southern Arkansas University - the most affordable, fastest growing university in Arkansas

Step 1 of 7

Please note

Student information

Emergency contact

Health questionnaire

Health history

Health/fitness pre-participation screening questionnaire for students

Mulerider Activity Center

Release and Healthcare Verification

Agreement and Release of Liability Form

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