Author: Kirkpatrick, Mark George

East Central University
Intramural Department

Intramural ID Number________________

Intramural League Semester Registration Application

Participant Name
Phone Number
E-mail
Mailing Address
City/State//Zip

I, ________________________________, desire to participate in the following Intramural activity _________________________________, and I fully understand and appreciate the dangers, hazards, and risks inherent in the Activity. I understand that releasees will not have medical personnel available during the Activity. I understand and agree that releasees are granted permission to authorize emergency medical treatment, if necessary, and that such action by Releasees shall be subject to the terms of this agreement. I understand and agree that Releasees assume no responsibility for any injury or damage which might arise out of or in connection with such authorized emergency medical treatment. I understand that the Institution does not require me to participate in this activity, but I want to do so, despite the possible dangers and risks. I further state that I am at least eighteen (18) years of age and fully competent to sign this agreement.
_______________________________________________ (Participant Signature)

Below Section for Office Use ONLY:

Payment Options: Cash / Check / Credit Card
Todays Date_____/_____/_____ Receipt Number____________
Amount Collected $_20.00_ Staff Initial________

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Visa MasterCard Discover __ __ __ __ /__ __ __ __/__ __ __ __/__ __ __ __
Name on card:_____________________________ Exp. Date __ __/__ __