Name: _________________________________________________ Team Name: ________________________________
Address: ___________________________________________________________ Jersey Number: ___________________
City: ____________________________ State: ______________ Zip: ______________
Home Phone: _____________________ Work Phone: ______________________ Email: ______________________
Please indicate the method of payment enclosed with application: Check ____ Credit Card____
Visa ___ M/C ___ Monthly Payments: 2 ($244); 3 ($162.67); 4 ($122) Amount to Charge: $___________________
(circle one)
Name as it appears on the card: _____________________________________ Exp. Date: __________
(Please Print Clearly)
Card Number:
For credit card payments: Please fill out the Registration Form and send it to your team captain, or to us via:
Fax: 925-634-7429 Voice Mail: 1-800-PLAY-PHA Email: pha@playpha.com U.S. Mail: below
For payment by check: Please fill out the Registration Form and send it, along with your check made payable to the Pacific Hockey Association or PHA, to your team captain, or to us at: PHA , P.O. Box 1433, Alameda CA 94501
2010 - 2011 PACIFIC HOCKEY ASSOCIATION WAIVER AND RELEASE OF LIABILITY AND MEDICAL AUTHORIZATION
-PLEASE READ CAREFULLY -
In consideration of being allowed to participate in the ice hockey program and any other activities sponsored by Pacific Hockey Association (PHA), each of the undersigned acknowledge and agree as follows:
I ACKNOWLEDGE AND FULLY UNDERSTAND that I will be engaging in hazardous sports activities that involve risk of serious injury, including permanent or partial disability and death which could result in economic and non-economic losses. I UNDERSTAND AND ACKNOWLEDGE that such serious injuries, death or partial or permanent disability may result from my own actions, inactions or negligence, but also from the action, inaction or negligence of other players, the referees, the rules of play, the condition of the premises or competition areas, or any equipment used or others. Further, I UNDERSTAND AND ACKNOWLEDGE that there may be other risks not known to me or not reasonably foreseeable at this time. I HEREBY EXPRESSLY ASSUME ALL RISKS associated with my participation in PHA ice hockey programs and other activities sponsored by PHA.
I AGREE NOT TO SUE AND AGREE TO RELEASE FROM LIABILITY PHA, their representatives, employees, agents, owners, landlords, any ice rink owners providing ice time to PHA, for any damage, injury or death arising out of my participation in PHA ice hockey programs and any other activities sponsored by PHA regardless of the cause, including NEGLIGENCE.
In the event I should sue anyone for personal injuries or other damages occurring during the course of PHA ice hockey programs and any other activities sponsored by PHA, I AGREE TO DEFEND, INDEMNIFY AND HOLD HARMLESS PHA for any actions, demands or claims made against PHA arising out of my suit.
I RECOGNIZE that I may require medical or dental care as a result of my participation in PHA ice hockey programs and any other activities sponsored by PHA. I AUTHORIZE PHA and its agents or employees (including but not limited to referees) to render first aid and to call for medical and dental care for me if, in the opinion of PHA or its referees, representatives, owners, employees, agents, medical or dental care is needed. I AGREE to pay for all expenses and costs associated with such care and related transportation. However, I EXPRESSLY RELEASE PHA from any and all liability arising out of PHA’s decision to render or not render first aid or to call for medical and dental care and EXPRESSLY ASSUME THE RISK of PHA representatives, employees, agents, or referees not rendering first aid or calling for such medical or dental care.
I UNDERSTAND that the foregoing is a WAIVER AND RELEASE OF LIABILITY and a MEDICAL AUTHORIZATION that is legally binding on me, my heirs and my legal representatives and I sign it of my own free will. I acknowledge that the foregoing is binding during all 2010 - 2011 seasons.
I ACKNOWLEDGE AND UNDERSTAND that the discounted payment of the team registration fee of $7,320 (“team fee”), if received by the League by October 11, 2010 is the obligation of each and every team. I ACKNOWLEDGE AND UNDERSTAND that in the event my entire team does not pay the discounted team fee in full by October 11, 2010, my individual payment will increase to $520 for the season. In addition, if the team is not eventually paid in full, I am liable to PHA for payment of my pro-rata portion of the team fee, meaning that my liability will equal the sum of then undiscounted team fee divided by the number of registered players on my team, unless otherwise noted in the $ Amt. Further, payment of said amount will be a condition of my participation in future PHA sponsored ice hockey programs and activities.
DO NOT SIGN IF YOU DO NOT UNDERSTAND IT OR IF YOU DISAGREE WITH ITS TERMS
Signature: _______________________________________________ Dated: ____________________