24-25 Non-CSUMB Student Club Membership Form

General Information

Today's Date *

Last Name *

First Name *

Name of College/University Enrolled *

Name of Sports Club *

Name of Additional Sport Club(s) *

Address *

Date of Birth *

Medical Information

Name of Primary Care Physician *

If you do not have a primary physician or your physician is unavailable, may CSUMB appoint a physician to treat you? *

Yes

Name of Emergency Contact *

Relationship of Emergency Contact to You *

Emergency Contact Address *

Emergency Contact Cell Phone *

Emergency Contact Email *

Medical History

Date of Last Tetanus Booster

List medications you are currently taking & for what reason *

List any allergies, your reaction to them and medication required *

List conditions for which you have been hospitalized within the past year or for which you are now undergoing treatment. *

Please list any medical symptoms, conditions, injuries, or treatment you feel is relevant to your participation in the Sports Club program. *

Insurance

Insurance
All participants must carry medical insurance. All participants are responsible for individual medical insurance & expenses.

Do you have medical insurance? *

Yes

Name of Insurance Company *

Insurance Policy Number *

Name of Insurance Policy Holder *

I have completed the medical history section to the best of my ability with full knowledge that any information withheld may increase the potential for injury or re-injury. *

Yes

Authorization for Emergency Medial Care

I am aware of my past and present health and fitness in relationship to strenuous activity. I will participate in all activities except for those noted above by myself and/or my physician. Information about any and all prescription drugs that I am currently taking is noted. Should an accident or emergency occur that renders me unable to communicate, I hereby give permission to the physician selected by CSUMB Sports Club staff to hospitalize and/or secure proper treatment for me, except as noted below. *

Yes

Failure to complete and submit this form will mean that you will not be able to participate in any Sports Club at CSUMB. Regardless of your physical condition, you are expected to pay attention to your body and its physical limitations to select an appropriate level of participation. Failure to complete all portions of this form could result in injury or compound the damage to an existing injury.

In accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the student(s) and CSUMB shall respect the confidential nature of all information that they have access to, including but not limited to patients' personal health information provided to them orally, contained in patient medical records or maintained on the University's electronic information system. *

Yes

Sports Club Release of Liability 2023 - 2024

Participation in California State University, Monterey Bay Sports Club program for the 2023/2024 academic year. The Sport Club program includes all clubs registered and chartered through the Sports Club Council that have been granted Sport Club recognition by Cal State Monterey Bay.

2023-2024 Academic Year

CSUMB Sports Club activities including all on-campus and off-campus club activities, competitions, games, performances, demonstrations, clinics, practices, meetings and travel.

Name of Sports Club *

I have read this document, and am signing it freely. No other representation concerning the legal effect of this document have been made by me. *

Yes

I agree

Yes

Print Your Name *

Today's Date *

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