Coastal Carolina University

Department of Kinesiology
Assumption of Risk, Release, Indemnification and Hold Harmless Agreement

I, , (please print full name) affirm that I am over the age of 18 and am
voluntarily participating in the Department of Kinesiology (KNES) course of
(please print course number and title) either in-person, via online instruction, or a hybrid of the two. I further acknowledge that I
know, understand, and appreciate the inherent risks of participating in the coursework for this course which requires my
participation in moderate to vigorous physical activity. I fully accept and assume all risks, whether foreseeable or not, and all
responsibility for any losses, costs, expenses, liabilities and damages that I may incur as a result of or in connection with my
participating in this course.

______ (Initial) I hereby accept and assume all risks, known and unknown and assume all responsibility for the losses, costs,
and/or damages following such injury, disability, paralysis, or death caused by or resulting from my participation in a variety of
exercise activities including but not limited to; activities involving cardiovascular fitness, body composition, muscle strength,
muscular endurance, and flexibility.

______ (Initial) I hereby understand Cardiovascular activities, such as the Rockport 1-mile walk, 6-minute walk, or graded
exercises may be performed. These activities could occur outdoors or indoors, with other students present. With these types of
cardiovascular activities, the workload is increased every few minutes until exhaustion or until other symptoms dictate that the
activity be terminated. Graded exercise activities will be terminated when a predetermined heart rate is reached. I further
understand that during any cardiovascular activity, certain changes such as abnormal blood pressure responses, fainting,
irregularities in heartbeat, and heart attacks may occur.

______ (Initial) I hereby understand body composition activities, such as the skinfold procedure involves the pinching of skin
in areas such as the back of the upper arm, the front of the abdomen, and the front of the thigh and that these procedures may be
performed on me. Additionally, circumference measurements with a measuring tape may be taken around certain areas of my
body including but not limited to the waist and hips.

______ (Initial) I hereby understand I may be asked to perform muscular strength and endurance activities such as lifting
weights for a number of repetitions during activities in this course and that I may experience the pulling and/or straining of
muscles and muscle soreness during and/or after performing the activities.

______ (Initial) I hereby understand I may be asked to perform flexibility activities involving the stretching of joints through
their complete range of motion, and that I may experience the pulling and/or straining of muscles.

______ (Initial) I hereby understand, that should my participation in the course include in-person instruction, I will be required
to physically observe my fellow classmates perform the aforementioned activities while wearing a face covering and/or face
shield, and at times, my observations may not allow me to remain at a six-foot social distance from others. I further understand
that my participation in high-intensity activities will require a face-shield to be worn during my participation.

______ (Initial) I hereby understand that information I have about my health status and/or health history, especially with heart-
related symptoms may affect the safety of my activities. I understand that I am solely responsible for fully disclosing my
medical history/health history (including medications), as well as symptoms that may occur during any activity or exercise
training session. Prompt reporting of unusual feelings during the activity, or at any time during the course is required.

______ (Initial) I hereby affirm that I have disclosed any known physical or mental illness or weakness, including medications I
am taking, to the course instructor in writing, and understand that my failing to disclose such information could increase the
risks associated with my participation in activities.

______ (Initial) I hereby acknowledge and understand that the disclosure of my medical history will be evaluated by my
instructor or their designee and that I may be required to follow up with my primary physician for further medical clearance to
participate in the course.

______ (Initial I hereby acknowledge that I have disclosed any known physical or mental illness or weakness, including
medications I am taking, to the course instructor in writing, and understand that my failing to disclose such information could
increase the risks associated with my participation in activities.
______ (Initial) I hereby declare myself to be physically sound and suffering from no condition, impairment, disease, infirmity
or other illness that would prevent or otherwise interfere with my participation in any activities associated with this course.

______ (Initial) I hereby accept and assume all risks, known and unknown and assume all responsibility for the losses, costs,
and/or damages following such injury, disability, paralysis, or death caused by or resulting from my participation in the physical
activities including but not limited to; activities of cardiovascular fitness, body composition, muscle strength, muscular
endurance, and flexibility.

______ (Initial) I hereby understand that Coastal Carolina University requires an individual over the age of 18 and of sound
mental capacity to supervise my performance of any physical activity required of this course. I further understand that if I am
participating in this course online, a course instructor will not be physically present to supervise my performance of physical
activity and I will be personally responsible for ensuring an individual over the age of 18 and of sound mental capacity
supervises my performance of any physical activity required of this course.

______ (Initial) I hereby understand that should I, choose to perform the physical activity components of the course without a
supervisor, I increase the risk for injury, including permanent disability, or loss of life and such injury shall not relieve me of
any financial obligations related or arising from my participation in this course.

______ (Initial) I hereby release Coastal Carolina University, its current and former trustees, officers, directors, employees,
representatives, agents, and volunteers, from liability and responsibility, whatsoever for any claim of action that I, my estate,
heirs, executors, or assigns may have for any personal injury, property damage, or wrongful death arising from activities in
association with the course I have voluntarily chosen to take, whether caused by active or passive negligence of Coastal
Carolina University or otherwise, with the exception of gross negligence. By executing this document, I agree to hold Coastal
Carolina University harmless for any injury, including paralysis, permanent disability, or loss of life which may occur during
my participation in this course.

______ (Initial) I hereby agree to indemnify and hold Coastal Carolina University, its current and former Trustees, officers,
directors, employees, representatives, agents, and volunteers harmless from any demands, loss, liability, claims or expenses
(including attorneys’ fees), made against Coastal Carolina University by any third party arising out of or in connection with my
participation in the Kinesiology Course for which I have voluntarily chosen to participate in.

______ (Initial) This Agreement shall be interpreted and enforced in accordance with the laws of the State of South Carolina,
without regard to any conflicts or choice of law principles, and shall be as broad and inclusive as permitted by such laws.

Signature of Participant Date

Signature of Supervisor of Participant’s Physical Activity Date