CLUB REGISTRATION AND RELEASE FORM
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Team: __________________________
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[ ] I am currently a member and wish to register for:
[ ] I am not currently a member and wish to register for:
[ ] I am not a member, but am participating in:
Club Activity: Indian Hill Volleyball Club At Great Lakes Center (GLC)
Name _______________________________ Dept. ________ Loc/Room _______ Ext. _________
HRID ____________ SS# (if non-BL emp) N/A E-Mail _______________________
Home Address: Not Applicable Home Tel. Not Applicable
Forms without PANs or Social Security numbers will not be accepted.
[ ] Lucent employee (or retiree) [ ] Other Lucent entity employee (or retiree)
[ ] Non-Lucent employee
In consideration of my being permitted to participate* in the above mentioned
activity, I, for myself, my heirs, legal representatives, and assigns, do hereby
release said activity, GLV Inc., Great Lakes Center and the Lucent Technologies,
its employees and agents, from all suits, claims or demands of any kind, which may
result from my death, injury, loss or damage of any kind, occasioned by my
participation in said activity. This release in no way affects any rights I may
have under any applicable Lucent Technologies Pension or Benefit Plan.
It is my further understanding that the arrangements for such activity are solely
the undertaking of the participants and not Lucent Technologies Company.
I hereby warrant that I am of full age and free to give this release which I have
read and understand.**
Signed ______________________________________________________ Date _____________
Witnessed by ________________________________________________ Date _____________
** If the above person is not 18 years of age or over, the person may not be
allowed to participate in said activity.
* Refusal to sign this release disqualifies the applicant from authorized
participation in the activity.
FORWARD THIS SIGNED AND COMPLETED FORM TO THE CLUB ACTIVITY CHAIRPERSON.