Fifth-Year Membership Application

Submit the form below to request your free fifth-year membership. Please note that you are only eligible for a fifth-year membership if you previously had free access to the Weinstein Center. Only 2013 grads are currently eligible.

* Indicates required field.

Member Information

*Member name:

*University ID number:

Address:

City: State: ZIP code:

Home phone number:

Cell phone number:

*Email address:

Would you like to receive email updates? Yes No

Emergency Contact

Name of emergency contact:

Relationship to member:

Emergency contact phone number:

Hold Harmless Clause

By submitting this form, you understand and agree to the following Hold Harmless Clause:

I agree to indemnify the Commonwealth of Virginia, the Trustees of the University of Richmond, the University of Richmond, and all their officers, employees and agents hereinafter referred to as Indemnities, against all claims, or liability whatsoever arising from this agreement or the performance of this agreement including, but not limited to, the damage to or the destruction of any property or injury or death to any person including claims, losses, or negligent act, whether passive or active of Indemnities.”

All participants involved in recreational activities run the risk of possible injury by the very nature of sport and are encouraged to purchase health insurance. The Recreation and Wellness Department has no insurance for its participants, who should understand that play is at one's own risk.