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Club Sports Program Safety Officer Acceptance of Responsibility Form Name Club Sport Organization Name Academic Year PSU Email Day Phone Evening Phone Local Address Please check one of the following Coach Club Member I hereby accept the responsibility of serving as a Safety Officer for the. name of club sport organization I understand that in order to serve in this capacity I must maintain certifications in CPR AED and First Aid from a Club Sports Program approved provider. I understand that it is my responsibility to monitor the safety of the environment in which the is participating and report any unsafe conditions accidents and/or incidents to the Club Sport Coordinator. I understand that the will not be allowed to participate in any activity without a safety officer present. I agree to show valid personal identification when asked by any Club Sport Program or facility staff* Printed Name Signature Date. name of club sport organization I understand that in order to serve in this capacity I must maintain certifications in CPR AED and First Aid from a Club Sports Program approved provider. I understand that it is my responsibility to monitor the safety of the environment in which the is participating and report any unsafe conditions accidents and/or incidents to the Club Sport Coordinator. I understand that it is my responsibility to monitor the safety of the environment in which the is participating and report any unsafe conditions accidents and/or incidents to the Club Sport Coordinator. I understand that the will not be allowed to participate in any activity without a safety officer present. I understand that the will not be allowed to participate in any activity without a safety officer present. I agree to show valid personal identification when asked by any Club Sport Program or facility staff* Printed Name Signature Date. name of club sport organization I understand that in order to serve in this capacity I must maintain certifications in CPR AED and First Aid from a Club Sports Program approved provider. I understand that it is my responsibility to monitor the safety of the environment in which the is participating and report any unsafe conditions accidents and/or incidents to the Club Sport Coordinator. I understand that the will not be allowed to participate in any activity without a safety officer present. I understand that it is my responsibility to monitor the safety of the environment in which the is participating and report any unsafe conditions accidents and/or incidents to the Club Sport Coordinator. I understand that the will not be allowed to participate in any activity without a safety officer present. I agree to show valid personal identification when asked by any Club Sport Program or facility staff* Printed Name Signature Date..

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