Chez Veteran Center Registration

Chez Veteran Center Registration

Dear Prospective Student:

Thank you for your interest in services for military-connected students (veterans, guard/reservists, and dependents, ect.) offered by the Chez Veteran Center (CVC). It is important that you complete this application and an orientation session to maximize Center services. Once you complete this application, you will be contacted by a Chez Veteran Center staff member to schedule an orientation session.

In participating in registration and an orientation session at the Center, I hereby acknowledge that I have been informed of the following stipulations and find them acceptable:

  1. The purpose of the orientation is to help Center staff to direct me to appropriate services (e.g., referral for counseling services, academic accommodations, academic services, career services, and/or VA services).
  2. I understand that confidentiality rights apply (per FERPA, HIPPA, and Illinois Mental Health and Developmental Disabilities Confidentiality Act), meaning that the information I supply today will not be released to anyone without my consent, except when there is reasonable concern that harm may come to myself or others (child or elder abuse, suicide, homicide).
  3. I understand that the Center staff are considered responsible employee of the University of Illinois and obligated to take actions to address complaints of sexual violence to the University Title IX & Disability Office. This does not include a clinician who is considered a confidential resource when in a therapeutic role (e.g. Individual, Couple, Family or Group Therapy).
  4. If, as a result of the interview, I am referred for services, I understand that no one other than Chez Veteran Center personnel have immediate access to my CVC files, and that any information regarding my disability that is gained from these files shall be considered confidential and will only be shared with others within the institution on a need-to-know basis. I further understand that my reports will not be released by CVC except in accordance with federal and state laws.

I. BACKGROUND INFORMATION

 

required2. Gender

required2. Gender

 

 

 

answer must be an email address

 

 

8. Race/Ethnicity (optional for statistical purposes) Select one or more:

8. Race/Ethnicity (optional for statistical purposes) Select one or more:

answer must be phone number with area code like 217-333-1000

 

Emergency Contact

 

answer must be phone number with area code like 217-333-1000

 

 

II. UNIVERSITY OF ILLINOIS ENROLLMENT

required14. Status

required14. Status

 

 

17. Current Year in School

17. Current Year in School

18. Education Benefit (select all that apply)

18. Education Benefit (select all that apply)

III. ACADEMIC HISTORY

required20. Are you currently receiving services through DRES?

required20. Are you currently receiving services through DRES?

IV. GENERAL NATURE OF DISABILITY / DISABILITIES

required21. Do you receive VA Compensation and Pension benefits?

required21. Do you receive VA Compensation and Pension benefits?

22. If service-connected: what is your percentage?

22. If service-connected: what is your percentage?

V. Center Registration Information and/or Needs

required23. Services Requested (select all that apply)

required23. Services Requested (select all that apply)

By checking 'Utilize the Center's facilities', you agree to the following: 

In consideration of my use of the exercise equipment and facilities provided by The Chez Veteran Center (CVC), located at 908 W. Nevada St. Urbana, Illinois, I expressly agree and contract, on behalf of myself, my heirs, executors, administrators, successors and assigns, that the company and its insurers, employees, officers, directors, and associates, shall not be liable for any damages arising from personal injuries (including death) sustained by me, or my guest in, on, or about the premises, or as a result of the use of the equipment or facilities, regardless of whether such injuries result, in whole or in part, from the negligence of the company.


By the execution of this agreement, I accept and assume full responsibility for any and all injuries, damages (both economic and non-economic), and losses of any type, which may occur to me or my guest, and I hereby fully and forever release and discharge the CVC, its insurers, employees, officers, directors, and associates, from any and all claims, demands, damages, rights of action, or causes of action, present or future, whether the same be known or unknown, anticipated, or unanticipated, resulting from or arising out the use of said equipment and facilities.


I expressly agree to indemnify and hold the CVC harmless against any and all claims, demands, damages, rights of action, or causes of action, of any person or entity, that may arise from injuries or damages sustained by me or my guest.


I agree to be solely responsible for safety and wellbeing of my guest and myself. I understand that the CVC does not provide supervision, instruction, or assistance for the use of the facilities and equipment.

I agree to comply with all rules imposed by the CVC regarding the use of the facilities and equipment. I agree to conduct myself in a controlled and reasonable manner at all times, and to refrain from using any equipment in a manner inconsistent with its intended design and purpose.


I understand and acknowledge that the use of exercise equipment involves risk of serious injury, including permanent disability and death, and that I should contact my personal physician before engaging in any fitness activity.


I understand and agree that the CVC is not responsible for property that is lost, stolen, or damaged while in, on, or about the premises.