Walk-on Waiver Forms

Walk-On Waiver of Liability I, the undersigned hereby request permission to try out for a position on the LSSU ______________________ team. I have participated in athletic activities related to said sport before and I am fully aware of the risks and dangers involved. I am aware that unanticipated and unexpected events may occur during such activities that may result in injury to me. I hereby assume all risks of injury that may be sustained by me in connection with said activities. I certify that my participation in the stated activities is voluntary. In consideration of my being allowed to try out for said sport, I hereby release and forever discharge Lake Superior State University, its officers, agents, and employees, and further covenant not to sue said University, its officers, agents, and employees. I clearly understand that this waiver is complete and valid only upon my presentation of proof of billable health insurance and completion of all insurance forms, signed and returned to the Sports Medicine Department. The said insurance policy must cover athletically related injuries in the state of Michigan. In addition, I clearly understand that this waiver is only good for a maximum of 21 days from the day it is signed. If I am to be sanctioned as a LSSU student-athlete and if the coaching staff has chosen me for the team, I must obtain a physical exam by the LSSU Sports Medicine Staff and complete all eligibility requirements. I also understand that it is my responsibility to fulfill these requirements within the 21-day period. The dates of participation are (21 days maximum): ______________ to _____________. Dated this ________ day of ________________, 20____. Insurance on file: _______________________________________. ______________________________________________________ Student-Athlete’s Printed Name ______________________________________________________ Student-Athlete’s Signature ______________________________________________________ Parent Signature if Student-Athlete is Under 18 ______________________________________________________ LSSU Certified Athletic Trainer Signature

____________ Date of Birth

Lake Superior State University EMERGENCY CONTACT and INSURANCE INFORMATION Name

________________________________________________________________________

Date of Birth

______________________

Sport

SSN

______________________

Academic Year ____________________________

____________________________________

The Acknowledgement of Insurance Requirements must be read and understood and this form completed PRIOR to the student-athlete participating in practice and/or competition. __________________________________________________________________________________________ Parent/Guardian Name ________________________________________________________________ Address

________________________________________________________________________

______________________________________________________________________________________ Home Phone _______________________ Work Phone ____________________________ __________________________________________________________________________________________ Policy Holder Name

________________________________________________________________

Relationship to Student-Athlete _________________________________________________________ Address

_______________________

_____________________________________ Insurance Company Name

Home Phone

____________________________

Work Phone

____________________________

_________________________________________________________

Insurance Co. Address ________________________________________________________________ Insurance Co. Phone Group #

________________________________________________________________

______________________________

Effective Date of Policy ________________ Primary Physician

I.D. # ___________________________________ Expiration Date ____________________________

________________________________________________________________

Office Number _______________________________________________________________________ Policy Limit

_______________________

Policy Co-Pay _______________________

Policy Deductible HMO/PPO

____________________________

____________________________

Does the policy cover injuries resulting from intercollegiate athletics? ____________________________ __________________________________________________________________________________________ I have read and agree to comply with the provisions of the Acknowledgement of Insurance Requirements. _________________________________________ Parent/Guardian Signature and Date

____________________________________ Student-Athlete Signature and Date