Faculty and Staff Registration Step 1 of 2 50% Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Work PhoneCell Phone*Employee ID# Date of Birth* MM slash DD slash YYYY Gender* Male Female Registration Type* New Registration Continued Registration Membership Length and Fees* 6 Month Membership - $90.00 12 Month Membership - $180.00 I hereby authorize the State Comptroller to start the deduction of $6.92 from each paycheck and remit said amount to UConn Health.* First Last Date* MM slash DD slash YYYY I acknowledge a full understanding of the inherent dangers and risks associated with the use of the UConn Health Wellness Center (“Wellness Center”) and/or any fitness/wellness activity occurring therein. I also acknowledge that it is my responsibility to follow any instructions for any activity or use of equipment. I further understand that, notwithstanding precautions taken by the University of Connecticut, UConn Health, and/or their affiliates (collectively, “UConn”), my use of, presence in, or participation in activities conducted by the Wellness Center involves a risk of injury and/or death. I am voluntarily participating in these activities and voluntarily using equipment, and I accept any and all risks associated with my participation in activities conducted at the Wellness Center. I acknowledge it is recommended that I seek approval from my physician before implementing an exercise regimen, as there may be significant health risks associated with exercising. In consideration for being permitted to use the Wellness Center, and because I assume all risks involved, I hereby agree that I am responsible for any resulting personal injury, damage to, or loss of my property arising out of my use of the Wellness Center, or participation in any fitness/wellness activity occurring therein. I, for myself, and on behalf of my heirs, assigns, personal representatives and next of kin, hereby release, indemnify, and hold harmless UConn, its officers, directors, trustees, agents, and/or employees (“Releases”) from any and all claims, demands, damages, rights of action or causes of action, present or future, arising out of my use or occupancy of the Wellness Center or any fitness/wellness activity occurring therein, including any injuries arising from negligence of the Releases or otherwise, to the fullest extent permitted by law. I further state that I am at least eighteen (18) years of age and fully competent to sign this document. I agree to pay all applicable fees, and I execute this waiver and release for full, adequate, and complete consideration fully intending to be bound by the same. Authorization* I have read and understand this Registration & Waiver and Release form and I am the person signing this form. NameThis field is for validation purposes and should be left unchanged.