Protection of Privacy - Personal information provided is collected in accordance with Section 4(c) of the Alberta Protection of Privacy Act (POPA) and will be protected in accordance with section 10 and used and disclosed in accordance with sections 12 and 13 of the Act. It will be used and/or disclosed for the purpose of administering the AUGUSTANA FITNESS CENTRE  and/or to communicate with the emergency contact in case the participant is seriously injured or ill.

 

Please note that information collected will be transmitted to and stored on servers outside of the University, Alberta and Canada and that the University cannot guarantee protection against disclosures as a consequence of foreign laws.

 

The University of Alberta uses automated systems to generate content and to make decisions, recommendations, and predictions. The personal information collected may be included in these automated systems. Should you require further information about collection, use and disclosure of personal information, please contact contact details here: Kelsy Haesloop, Student Experience Coordinator, Augustana Fitness Centre, 1-287, 4901-48 Ave Camrose, T4V 2R3, phone: (780) 679-1576, email: augfit@ualberta.ca

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RELEASE OF LIABILITY, ASSUMPTION OF RISKS AND INDEMNITY AGREEMENT
PLEASE READ CAREFULLY
BY SIGNING THIS FORM, YOU ACCEPT CERTAIN LEGAL OBLIGATIONS AND GIVE UP IMPORTANT LEGAL RIGHTS, INCLUDING THE RIGHT TO SUE



Review University of Alberta Privacy Policy

Assumption of Risks

In consideration of my participation in Augustana Campus Fitness Centre, I acknowledge that I am aware of, and freely accept all risks, dangers and hazards associated with being a participant at the Augustana Campus Fitness Centre, including the possible risk of severe or fatal injury to myself or others. These risks include, but are not limited to:

  1. Injuries or illness resulting from failure to follow directions, instructions and guidelines provided by those in charge of the Augustana Campus Fitness Centre;
  2. Injuries resulting from use, misuse, non-use or failure of any equipment, including, but not limited to, broken bones, muscle strains and sprains, soft tissue injury such as cuts and abrasions, spinal injury, concussion, and dental damage;
  3. Injury resulting from impact with obstructions, equipment, other participants or spectators;
  4. injury arising from falling and impacting against the floor surface, walls, apparatus/equipment;
  5. Where the activity is outdoors:
  •   Injury or loss arising from falls on ice or on steep, slippery or uneven terrain during travel to the location of the activity;
  •  Injury and/or illness resulting from exposure to weather conditions, including but not limited to cold, snow, ice, wind, hail, rain, sleet, fog, etc;

        6. An increased load on the heart, which may result in dizziness, shortness of breath and in extreme circumstances, may result in a heart attack;

        7. The risk of theft, vandalism or loss of personal property; and

        8. Potential exposure to infectious and communicable disease, including but not limited to COVID-19.

 

Release of Liability and Indemnification

In consideration for the University allowing me to participate in the Augustana Campus Fitness Centre, I agree:

1.      that the Governors of the University of Alberta, their officers, employees, and volunteers (hereinafter referred to as the “University”) are not responsible for any loss, damage, injury or expense of any kinds sustained by me while participating in the Augustana Campus Fitness Centre and all related activities, except to the extent that any loss, damage, injury or expense might result from the negligence of the University; 

2.      to WAIVE ANY AND ALL CLAIMS that I have or may in the future have against the University arising out of any aspect of my participation in the Augustana Campus Fitness Centre and to RELEASE the University from any and all liability resulting from any loss, damage, injury (including death) or expense that I may suffer as a result of my participation in the Augustana Campus Fitness Centre, due to any cause whatsoever, including without limitation, negligence, breach of contract, or breach of any statutory or other duty of care, as well as any duty of care owned under the Occupiers’ Liability Act (Alberta) on the part of the University;

3.      to INDEMNIFY AND HOLD HARMLESS the University in relation to:

      a.     any damage to University property caused by me;

     b.    any and all liability for any damages to the personal property of, or personal injury to, any third party resulting from my participation in the Augustana Campus Fitness Centre; and

      c.    any and all claims, demands, actions and costs which might arise out of my participating in the Augustana Campus Fitness Centre, except to the extent that such claims, demands, actions and costs may have been caused by the negligence of the University.


 

Acknowledgement

I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTOOD THIS AGREEMENT before signing it, that I have executed this Agreement voluntarily, and that this Agreement is to be binding upon myself, my heirs, executors, administrators and representatives. Further, I acknowledge and agree:

  1. To follow all rules and guidelines set out by the University and its representatives related to the Augustana Campus Fitness Centre and all related activities.
  2. As an employee or student of the University of Alberta, I am bound by the Ethical Conduct and Safe Disclosure Policy (employee) or the Code of Student Behaviour (student) and I agree to conduct myself accordingly at all times.
  3. That I will use any equipment within my abilities, or ask for instruction or guidance in its use.
  4. That I will wear appropriate attire for indoor or outdoor activities, including footwear, for the Augustana Campus Fitness Centre.
  5.  I will follow all guidelines for infection prevention and control as instructed, including social distancing, hand hygiene, and wearing personal protective equipment (eg. gloves, masks) to protect myself against COVID-19 and other communicable diseases.
  6. I will follow health authority self-isolation guidelines and stay home if I feel ill.

 



First Participant's Name
First Name*
Last Name*
Phone*
First Participant's Age Acknowledgment*
First Participant's Date of Birth*
Date of Birth
I certify that I am 18 years of age or older
First Participant's Signature*
Second Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Third Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Fourth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Fifth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Sixth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Seventh Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Eighth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Ninth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Tenth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Parent or Guardian's Email Address
Email*
Confirm Email*
Participant's Address
Address Line 1:
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:
City:
State/Province:
Zip/Postal:
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Emergency Contact
First Name*
Last Name*
Emergency Contact's Phone Number*
Emergency Contact's Relation to Participant
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Last Name*
Relationship*
Phone*
Address Line 1:
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:
City:
State/Province:
Zip/Postal:
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
Date of Birth
I certify that I am 18 years of age or older
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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