HPER for Fitness

Registration Form 

Personal Information 
Name   
Age   
Gender (Female or Male)   
           
Street Address   
City | State | ZIP   
Home Phone   
Work Phone   
Cell Phone   
Email Address   
 Convenient Times 
Check the time(s) which are most 
convenient for you to participate.		  
           
Areas of Interest 
Check the program(s) you would
like to participate in.		  
         
Person to Notify in Case of Emergency 
Name   
 Street Address    
City State Zip   
Home Phone   
Work Phone   
Email Address   
Agreement and Consent  

By checking the box below and/or submitting this application, I affirm that the facts set forth in it are true and complete.  As a participant in the HPER for Fitness Program, I do hereby forever waive, release and discharge the HPER faculty members and interns from any and all claims or liabilities for injuries or damages to my person and/or property including those caused by the negligent act or omission of any of those mentioned or others acting on their behalf, arising out of or connected with my participation in any fitness activities, training program, equipment, or aquatic center.

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It is the policy of this organization to provide equal opportunities without regard to race, color, religion, national origin, gender, sexual preference, age, or disability.

Thank you for completing this application form and for your interest in the HPER for Fitness Program. 
   

 

 
 
1000 ASU DRIVE   |   ALCORN STATE MISSISSIPPI 39096-7500   |   PHONE: 601.877.6100