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.

Regular physical activity is fun and healthy, and safe for most people. However, some individuals may have health-related risks that might require them to check with their physicians prior to starting an exercise program. To help determine if there is a need for you to see your physician before starting an exercise program, please read the following questions and answer carefully. All information will be kept in the strictest confidentiality.

If you answered "yes" to any of the above questions, it is recommended that you consult with your physician via phone or in person before participating in a physical activity program.

By submitting this form I understand that I am voluntarily participating in an athletic or physical activity at The MAC with full knowledge and understanding and appreciation of the risk of injury inherent in any physical exercise, massage or therapy program, physical activity, or athletic activity and expressly assume all risk of injury and even death, which could occur by reason of my participation. I release The MAC from any liability and agree not to sue the MAC with respect to any cause of action for bodily injury, property damage, or death occurring to me as a result of my participation in the activity. I understand that all personal property brought to the MAC is brought at my sole risk as its theft, damage, or loss.

Regular physical activity is safe for most people. However, some individuals should check with their doctor before they start an exercise program. To help us determine if you should consult with your doctor before starting to exercise with ( your organization), please read the following questions carefully and answer each one honestly. All information will be kept confidential.

I have read, understood, and completed this health history questionnaire. I made sure to seek out answers to any questionsto my full satisfaction.

If you marked two or more of the statements from the "Symptoms", "Other health issues", and "Cardiovascular risk factors" sections, you should consult your healthcare provider before engaging in exercise. You might benefit from using a facility with a professionally qualified exercise staff to guide your exercise program. If none of the above is true for you, you should be able to exercise safely without consulting your healthcare provider in almost any facility that meets your exercise needs.

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 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).

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.