FIU - ELI - Gym Access Request

FIU Wellness and Recreation Center Special Group Membership Form

Recreation Center - Modesto A. Maidique Campus
11290 S.W. 12th Street Miami, Florida 33199 Telephone: 305-348-2951 Website: recreation.fiu.edu
Please Read the Following:
1. You must be a student of the English Language Institute. 2. You must have your FIU One Card before requesting access to the Wellness & Recreation Centers (Gym). 3. This request is only valid for the current term. 4. If you would like access next term, please complete this form again at that time.
FIU E-Mail
Last Name
First Name
Middle Name
Photo

Attach Files
Date of Birth Date of Birth / MM / DD YYYY
Telephone Number Telephone Number - ### - ### ####
Panther ID Number
Must be 7 characters. Currently Entered: 0 characters.
Please use the seven digit number that appears on the front of your Panther ID card.
U.S. Address U.S. Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Emergency Contact: Last Name, First Name
Emergency Contact: Telephone Number
Current Term

Please select the current term you are attending.
Terms and Conditions
In consideration for permission to participate in the recreation & fitness activities offered by Florida International University (FIU) Department of Recreation Services (Department), on behalf of myself, my spouse/same-sex partner, family, heirs, and assigns (collectively, Me), I release and hold harmless FIU, the Florida Board of Governors, the FIU Board of Trustees, the State of Florida, its employees & agents (collectively the University) from liability arising from injury, death or property loss suffered by Me which may result from the negligence of the University while using recreational facilities, equipment, or participating in Department-sponsored activities. I acknowledge that I know, understand, and appreciate the inherent risk of using recreation & fitness equipment and facilities, and participating in the recreation & fitness activities that I choose. I know that these risks range from minor scrapes, strains, and bruises to significant injuries, such as broken bones, eye injury or loss, concussions, paralysis, and even death, and may result from my action, others' actions, or both. By signing this Agreement, I fully assume the inherent risks associated with using the facilities, equipment and participating in the activities provided the Department, and assert that my use of or participation in them is voluntary. I further agree to abide by the terms and conditions contained on the Recreation Center website. For Policies and Procedures please visit: www.recreation.fiu.edu. I have read the above FIU Recreation Services Waiver of Liability and Assumption of Risk Agreement and by signing it, agree that it is my intention to exempt and relieve the State of Florida, Florida Board of Governors, the Florida International University Board of Trustees, and/or FIU from liability for personal liability, property damage or wrongful death caused by negligence or any other cause or action.
Do you accept the terms and conditions?

Do you accept the terms and conditions? Yes, I accept the terms and conditions.
Are you a current student at FIU-ELI?

Are you a current student at FIU-ELI? Yes, I am a current student at FIU-ELI.
Disclaimer
Your access will be available in approximately one to two business days.
Draw your signature into the box below.

Draw or Type

By digitally signing this document you agree to the terms above. Clear

Full Name

By digitally signing this document you agree to the terms above.
Date Date / MM / DD YYYY