ROLLERAMA II

6995 W. GRAND RIVER BRIGHTON, MICHIGAN 48114 (810) 227-2010

ROLLER HOCKEY LEAGUE

REGISTRATION FORM

PLEASE SIGN ME UP!

NAME AGE

ADDRESS CITY

STATE ZIP HOME TELEPHONE WORK TELEPHONE

CIRCLE WHICH LEAGUE YOU ARE SIGNING UP FOR : SATURDAY SUNDAY

DATE OF BIRTH MONTH DAY YEAR

WOULD YOU LIKE TO PLAY GOALIE? YES NO MAYBE

HOW DID YOU HEAR ABOUT OUR PROGRAM?

WOULD YOU (OVER 18) OR ANYONE YOU KNOW BE INTERESTED IN COACHING?

NAME

PHONE

CONSENT AND LIABILITY WAIVER

THE UNDERSIGNED HAVING KNOWLEDGE OF THE PHYSICAL RISKS INVOLVED IN ROLLER HOCKEY PROGRAMS, WAIVE ANY CLAIM I (WE) MAY HAVE FOR MYSELF (OURSELVES) AND THE APPLICANT FOR ANY INJURIES SUSTAINED DURING THE COURSE OF ROLLER HOCKEY COMPETITIVE MATCHES, TOURNAMENTS, PRACTICES AND/OR INSTRUCTIONAL LESSONS. I (WE) FURTHER RELEASE ROLLERAMA II, IT’S EMPLOYEES AND AFFILIATES FROM ALL CLAIMS FOR DAMAGES OR LIABILITY RESULTING FROM APPLICANTS ACTIVITIES.

IN ADDITION, THE UNDERSIGNED HEREBY AUTHORIZES THAT IN THE EVENT OF A SUSTAINED INJURY, THE PROGRAM DIRECTOR OR HIS ASSISTANTS MAY SECURE TEMPORARY EMERGENCY CARE.

I AM OVER 18 YEARS OF AGE AND UNDERSTAND THE RISKS INVOLVEDIN NOT USING ALL OF PROTECTIVE EQUIPMENT REQUIRED FOR ROLLER HOCKEY. I HEREBY RELEASE ROLLERAMA II, ITS ASSIGNED REPRESENTATIVES AND AGENTS FROM ANY AND ALL LIABILITY.

REFUND POLICY: THERE WILL BE A $25.00 CHARGE FOR CANCELLATIONS PRIOR TO THE REGISTRATION DEADLINE FOR THE LEAGUE. AFTER THE REGISTRATION DEADLINE OF THE LEAGUE THERE WILL BE NO REFUNDS.

SIGNATURE (PARENT’S SIGNATURE IF UNDER THE AGE OF 18) DATE