Staple receipt & photo ids. Print Clearly.
Name: ______________________________________________ Date: ________________
Address: ____________________________________________ Time: ___:___am/pm
City: _____________________________________State: ______Zip__________________
Phone (___) ______________________________ home/office/cell
Is this your first visit? yes no
*PLEASE READ AND SIGN BELOW*
Rider University SRC members and their guests assume the risk of any and all accidents or injuries of any kind
which may be sustained by reason of or in connection with the use of the Student Recreation Centers’ facilities,
and release, discharge and absolve Rider University and its managing company, University Athletic
Management(UAM), agents and employees, from any and all liability or responsibility except if such accident
or injury is the result of the negligence of Rider University, UAM, its agents or employees.
Guest signature: _________________________
Rider University SRC Member Information
(Must present valid Rider ID)
Name: ________________________________________ ID#______________________
Phone: __________________________ home/office/cell
I hereby know and claim full responsibility for the behavior of my guest listed above
while we are within the Student Recreation Center.
RIDER SRC MEMBER SIGNATURE _____________________________________________
Guest fee paid: $_________ cash, check, (made out to Rider University) MC, VISA,
Reason Fee waiver: _____________________________________________________________
Staff Initials: __________
**Form must include a copy of both guest and SRC member’s valid (not expired) photo IDs and register