SPORT: ________________

Date:________________
Example: Mon. 12/11/06

UVM Intramural Roster and Assumption of Risk Agreement & Release Form Please Read Completely and Carefully before Signing.
Theundersignedparticipantshavereadandfullyunderstandtherisksandhazardsofpersonalinjury,includingdeathorlossofpropertythatmayarisethrough participationinanyIntramuralactivityincludingrisksorhazardsthatarisefromtransportationtoandfromevents,andsaidpersonsassumeallrisksassociatedwith theirparticipation. Bysigningbelow,saidparticipantsagreetoreleaseandholdharmlesstheUniversityofVermontanditsemployeesfromallliabilityintheeventofinjuriesor aggravatedphysicalconditionssustainedduring,orasaresultof,theirparticipation.Itisrecommendedthatallparticipantsconsultamedicaldoctorpriorto participation.(Playersundertheageof18musthaveaparent/guardiansignadifferentform). Bysigningbelow,saidparticipantsagreetopermittheUniversityofVermontCampusRecreationOfficetoreleaseinformationandpicturesregardingparticipation inCampusRecreationactivities. ParticipantsName(PRINTLEGIBLY) UVMID#(i.e.,950#)orSS# Signature TeamName

Gender M/F/T M/F/T M/F/T M/F/T M/F/T M/F/T M/F/T M/F/T M/F/T M/F/T M/F/T M/F/T M/F/T M/F/T M/F/T M/F/T M/F/T