Personal Information
Name:
Houston Address:
City:		State:	AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY	Zip:	(12345-6789)
Phone #:	(111-222-3333)
Gender:	Male    Female	Classification/Age:
Desired Activity
Please indicate which Intramural Sports activity you'd like to participate in.
Name of Activity:
Contact In Case of Emergency
Name:
Relationship:
Address:
City:		State:	AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY	Zip:	(12345-6789)
Phone #:	(111-22-3333)

Eligibility and Insurance Statement

ELIGIBILITY: All team participants must be currently enrolled at TSU, a member of the Recreation Center or can be verified by the Department of Human Resources to be a full or part time employee at TSU in order to complete in Intramural Sports.

INSURANCE: Texas Southern University is not responsible for personal injuries to persons participating in Intramural Sports. Texas Southern University offers a good insurance policy for the protection of students. It is a voluntary and inexpensive program that covers accidents resulting from intramural sports. All students who plan to participate in intramurals should join this insurance program. All residence hall students are covered. Students living off campus (Greystone, Courtyard, and Tierwester Oaks Apartments included) that do not have or are not sure of current membership should see the Student Health Center or the Intramural Sports Office to obtain information and forms to enroll in this policy.

By checking this box, I hereby acknowledge that I have read and understand the aforementioned "Eligibility and Insurance Statement."

Date:

(mm/dd/yyyy)