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Bill's
Dek Hockey
209
Bills Lane - Belle Vernon, PA
15012 - 724-379-DECK
Today's
Date____________
Date of Birth________________________
Age _____
NAME________________________________________________
PHONE # (
)__________________
STREET
ADDRESS________________________________
CITY___________________________ZIP______________
TEAM
NAME _________________________________________
(Ages 17 &
under) Parent/Guardian's name__________________________Emergency Phone #_________________________
_________________________________________________________________________________________________
Bill's
Dek Hockey Waiver and Release of Liability
In consideration
in being allowed to participate in any way in Bill's Dek
Hockey Leagues, tournaments, and/or any type of open play the undersigned
acknowledges, appreciates, and agrees that:
- The
risk of injury from the activities involved in this program is significant,
including the potential for permanent paralysis and death, and while
particular rules, equipment, and personal discipline may reduce this risk,
the risk of serious injury does exist; and
- I
KNOWINGLY and FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF
ARISING FROM THE NEGLIGENCE OF THE RELEASES or others, and assume FULL
responsibility for my participation; and
- I
willingly agree to comply with the stated and customary terms and conditions
for participation. If however,
I observe any unusual significant hazard during my presence or
participation, I will remove myself from participation and bring such to the
attention of the nearest official immediately, and
- I,
for myself, and on the behalf of my heirs, assigns, personal representatives
and next of kin, HEREBY RELEASE AND HOLD HARMLESS Bill's Dek Hockey , Bill's Golfland, Inc., their officers, officials, agents
and/or employees, other participants, owners and lessors or the premises
used to conduct the event ("Releasees") WITH RESPECT TO ANY AND
ALL INJURY, DISABILITY, DEATH, or lose or damage to person or property,
WHETHER ARISING FROM THE NEGLIEGENCE OF THE RELEASEES OR OTHERWISE.
I HAVE FULLY
READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY
UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY
SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.
X____________________________________________________
Date
____________________________
For
participants of Minority Age
(under
18 at the time of registration)
This
is to certify that I, as a parent/guardian with legal responsibility for this
participant, do consent and agree to his/her release as provided above of all
the Releases, and for myself, my heirs, assigns, and next of kin, I release and
agree to indemnify the Releases from any and all liabilities incident to my
minor child's involvement or participation in these programs as provided above,
EVEN IF ARISING FROM THEIR NEGLIGENCE.
X_______________________________________________
Date____________________________
ATR
6/10/11
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