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Prince Rupert Pick Up Hockey League - Registration

  PRINCE RUPERT PICKUP HOCKEY

  Adult Player Registration & Waiver Form

Player’s Name: ___________________________________________________   Date of Birth: _____ / _____ / ______ 

Address: ____________________________________________   City:  __________________   Postal: ____________

Home phone: _____________________________________   Business/Cell: __________________________________

Email: ___________________________________________  Player Position:  C ___  RW ___  LW ___  D ___   G ___

Skill Level: __________          Years Played: ___________       

WARNING: Please read this waiver carefully, by signing this agreement, you are affecting your legal rights and liabilities. 

Do not sign this agreement unless you have carefully read this entire Agreement, understand it, and agree with all of its contents.

RELEASE OF LIABILITY, WAIVER OF CLAIMS, ASSUMPTION OF ALL RISKS, & INDEMNITY AGREEMENT

I AGREE that I am over the age of 18 years, and that I, the undersigned, agree that in consideration of myself being permitted to enter and use the Jim Ciccone Ice Arena for ice hockey, and for ANY activities including, but not just limited to, ice hockey, DO HEREBY REMISE, RELEASE, INDEMNIFY, SAVE HARMLESS, DISCHARGE, AND FOREVER HOLD HARMLESS Prince Rupert Pickup Hockey League, and their directors, volunteers, instructors from any claims whatsoever arising by reason of any disease, deterioration of health, illness or injury to any person, including death, or for damage to, or loss of any of my property resulting from or arising from use of the lands and premises, from being present on the lands and premises, from participation in any program, from the use of any facilities or equipment located on the lands and premises, from acceptance of the advice of, or from the gross or willfull negligence of the Prince Rupert Pickup Hockey League their directors, volunteers, instructors, or any other persons using the lands and premises.  The activities that I will be participating in will be inherently dangerous, and I will be exposed to risk of serious injury, disability, death, and risk of damage to or loss of property.  I acknowledge that there may not be prompt access to medical assistance or treatment when participating in any activities, and I assume and accept any risk relating to the access to medical assistance and/or treatment.  By signing this document I acknowledge that I have read, understood and accepted the conditions of this waiver form and are waiving certain legal rights, including the right to sue.

PRIVACY CONSENT

I,_____________________________________________, do hereby consent to the collection and use of my personal information (including first and last name, address, phone number, postal code, email addresses, date of birth), personal images, athletic results and awards, prizes received, and verbal quotes, by posting on the website, or affiliated websites, of The Prince Rupert Pickup Hockey League.  I understand and agree that this information will not be sold to anyone without my prior written consent.  I understand that my personal information can be viewed by anyone who accesses Prince Rupert Pickup Hockey League websites or publications, and that my consent can be withdrawn at any time, upon adequate prior written notice.  I give this consent voluntarily and with the understanding that any of this information may be used in newspaper or magazine stories, posted on websites, and to verify my identity and registration with Prince Rupert Pickup Hockey League.

Dated: _____ / _____ / _____                  ____________________________________________________                   

                month      day           year                                  Player’s Signature

Your signature on this form will serve as your official signing of this release

Registration Fee $500.00 

OFFICE USE ONLY                                                                                                                                                                                

Date form received:  ____________________     Received by: _____________________________                         

CHQ #  _______     CASH    _______ 

Fee Paid:  YES          NO   (please circle one)      RCPT# _______

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