Wellness Room Request for Access and Release From Liability First and Last Name: * Email * I request access to the University of Michigan Ruthven Building Wellness Room (“Wellness Room”) for the purpose of voluntarily utilizing its exercise and fitness equipment and facilities. I understand there are risks associated with physically strenuous activities and use of exercise equipment and that it is my responsibility to evaluate these risks and consult with my health care provider for guidance prior to undertaking any exercise routine or regimen or utilizing the Wellness Room. I hereby release and hold harmless the Regents of the University of Michigan, its employees and agents from all claims and liabilities for injury, damage or loss arising from my use of the Wellness Room and its equipment and facilities. I acknowledge that security and assistance is not present 24 hours a day, 7 days a week. Initials * I understand the use of the Wellness Room and the equipment and facilities is not a work related activity and my use of the facility and equipment is on my own personal time. Initials * I have been given a copy of the Ruthven Wellness Room Rules and Guidelines. I understand the rules and guidelines and understand to whom I should direct questions. I have viewed the mandatory Wellness Room Orientation Program, and I agree to follow all Wellness Room rules, guidelines, instructions and safety precautions. Should I notice damaged or defective equipment, I will immediately tag the equipment with an “Out of Order” sign (located by the telephone) and immediately notify the Building Manager. I understand that failure to abide by the Wellness Room rules, guidelines, instructions and safety precautions may result in injury to me or others and/or a loss of privileges to use the Wellness Room. UMID * For card reader access Date * Name * Department * Paragraph If you are human, leave this field blank. Submit Δ Please allow 48 hours for processing of door access. Confirmation of access to the Wellness room will be verified with returned copy of electronically signed Request for access & Release of Liability form and guidelines.