| PACIFIC HOCKEY ASSOCIATION INDIVIDUAL PLAYER REGISTRATION FORM SUMMER 2008 BAY AREA BULLDOGS P.O. Box 1433 Alameda, CA 94501 1-800-PLAY-PHA Fax: 925-634-7429 e-mail: pha@playpha.com |
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Name: ______________________________ Team Name: BAY AREA BULLDOGS
Address: ________________________________________ Jersey Number: ___________________
City: __________________ State: ______ Zip: _________________
Home Phone: _______________ Work Phone: _________________ Email: _________________
Please indicate the method of payment enclosed with application: Check ____ Credit Card____
Visa ___ MasterCard ___ Amount to Charge: __ $____.00/MONTH OR __$_____.00 FULL PAYMENT
Name as it appears on the card: _____________________________________ Exp. Date: __________
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
2007 - 2008 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 2007 - 2008 seasons.
I ACKNOWLEDGE AND UNDERSTAND that payment of the team registration fee of $7,200 (“team fee”) is the obligation of each and every team. I
ACKNOWLEDGE AND UNDERSTAND that in the event my team does not pay the full team fee 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 the 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.
THIS IS A WAIVER AND RELEASE OF LIABILITY AND MEDICAL AUTHORIZATION
Signature: ___________________________________________ Dated: ____________________
Address: ________________________________________ Jersey Number: ___________________
City: __________________ State: ______ Zip: _________________
Home Phone: _______________ Work Phone: _________________ Email: _________________
Please indicate the method of payment enclosed with application: Check ____ Credit Card____
Visa ___ MasterCard ___ Amount to Charge: __ $____.00/MONTH OR __$_____.00 FULL PAYMENT
Name as it appears on the card: _____________________________________ Exp. Date: __________
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
2007 - 2008 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 2007 - 2008 seasons.
I ACKNOWLEDGE AND UNDERSTAND that payment of the team registration fee of $7,200 (“team fee”) is the obligation of each and every team. I
ACKNOWLEDGE AND UNDERSTAND that in the event my team does not pay the full team fee 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 the 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.
THIS IS A WAIVER AND RELEASE OF LIABILITY AND MEDICAL AUTHORIZATION
Signature: ___________________________________________ Dated: ____________________