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Registration Form

For your ease of use, please complete this form on a computer.

Then email it to albertso@email.unc.edu to schedule your Fitness Orientation.
Personal Information
Please type or print neatly, so we meet your needs accurately.
PID Number
Phone Number
Email Address
University Status 1st YR SO JR SR GRAD FAC/STAFF
Gender Male Female
Orientation Leader Gender Male Female No Preference
Facility Preference Rams Head Rec. Center Student Rec. Center
How did you hear about this Email Online SRC/RHRC Word of Mouth
service? DTH Special Event Other

Fitness Goals
Please use the drop-down menus to rank the accuracy of the five goals listed below.

Most Least
Important Important
1 2 3 4 5

Click - I want to improve my cardiovascular fitness Click - I want to reduce my body-fat

Click - I want to reshape or tone my body Click - I want to improve my flexibility
Click - I want to increase my strength Additional Goals:

Equipment Preferences
Please indicate the type[s] of equipment you are interested in learning about:
Exercise Bike Elliptical Trainer
Concept II Rower Treadmill
Stair Climber/Stepmill Strength Equipment
Other [please specify]:

Please email the completed registration form to Jordan Albertson,

albertso@email.unc.edu, in order to schedule an appointment.

Revised on 8.15.2008
University of North Carolina at Chapel Hill – Department of Exercise and Sport Science


In consideration of being allowed to participate in the activities and programs of the University of
North Carolina at Chapel Hill Department of Exercise and Sport Science and in consideration of the
voluntary nature of such participation and use, I hereby release, hold harmless, and forever discharge The
University of North Carolina at Chapel Hill, its employees and agents, from any and all liability, claims,
demands, actions, and causes of actions whatsoever arising out of or related to any loss, property damage,
or personal injury, including death, that may be sustained by me or to any property belonging to me, while
participating in such activity.

I, the undersigned, hereby give permission for the staff of the University to seek emergency medical
attention to be given for me to receive medical attention in the event of accident, injury or illness. I will be
responsible for any and all costs of such medical attention and treatment.

I understand and am aware that strength, flexibility and aerobic exercise, including the use of
equipment, are potentially hazardous activities. I also understand that fitness and recreational activities
involve a risk of injury and even death, and that I am voluntarily participating in these activities and using
equipment and machinery with knowledge of the dangers involved. I hereby agree to expressly assume
and accept any and all risks of injury or death.

I do hereby further declare myself to be physically sound and suffering from no condition,
impairment, disease, infirmity, or other illness that would prevent my participation or use of equipment or
machinery except as hereinafter stated. I acknowledge that I have either had a physical examination and
been given my physician’s permission to participate, or that I have decided to participate in activity and use
of equipment and machinery without the approval of my physician and do hereby assume all responsibility
for my participation and activities, and utilization of equipment and machinery in my activities.

I am fully aware of the risks and hazards associated with participation in physical activity. I hereby
elect voluntarily to participate in said activity and fully acknowledge that the activity may be hazardous to me
and my property. I agree to comply fully with the rules/regulations and directions provided by the staff at
any of the EXSS/Campus Recreation facilities. Further, I understand that I will be disqualified from the
activity in the event that I fail to comply with said rules.

This release and hold harmless agreement is binding on myself, my heirs, my assigns, and personal

I, ___________________________________________, am 18 years of age or older.

_____________________________________ _______________________________
Signature Date

Administrative Use Only:

With: _______________________ On: _____________ At: ____________
Information added to Participant Tracker
Receptionist Initials: ______________________

Revised on 8.15.2008

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