BIG WHEEL ROLLER HOCKEY LEAGUE 2011-2012 SEASON

 

LAST NAME: ______________________________FIRST NAME: ______________________

MAILING ADDRESS: __________________________________________ _

CITY:__________________________ STATE:____________________ ZIP CODE:____________________

HOME PHONE:( )________________________WORK PHONE: ( )______________ __

BIRTHDATE:______________________AGE:_______ EMAIL ADDRESS:__________________________

MOTHERS NAME:______________________OCCUPATION:____________________________________

FATHERS NAME: ______________________OCCUPATION: _ ______________________

SCHOOL ATTENDING:_________________ GRADE:__ ______

 

AMOUNT PAID_____________DATE____________________DIVISION_____________SESSION________________

AMOUNT PAID_____________DATE____________________DIVISION_____________SESSION________________

AMOUNT PAID_____________DATE____________________DIVISION_____________SESSION________________

 

WAIVER AND RELEASE OF LIABILITY - POCONO B.W., INC. & ANY AFFILIATES

(HEREAFTER REFERRED TO AS “BIG WHEEL”)

In consideration of being allowed to participate in any sports programs and other sponsored activities offered

by Big Wheel, the undersigned acknowledges and agrees as follows:

 

1. I acknowledge and fully understand that I will be engaging in activities that involve risk of serious injury, including

permanent disability and death and severe social and economic losses, which might result not only from my own actions,

inactions, or negligence, but also from the actions and inactions or negligence of others, the rules of play, or the condition

of the premises or competition area or any equipment used, further, that there may be other risks not known to me or

reasonably foreseeable at this time.

 

2. I agree that prior to participating in any activity sponsored by Big Wheel, I will inspect the competition area and

all equipment to be used, and if through my inspections, I determine that anything related to that activity is unsafe,

I will immediately advise my coach or an official of Big Wheel of this unsafe condition and will not participate until

the condition is corrected.

 

3. I assume all foregoing risks and accept personal responsibility for the damages following such injury, permanent

disability or death.

 

4. I release, waiver, discharge, and covenant not to sue Big Wheel, it’s affiliated clubs, their respective administrators,

directors, agents, attorneys, coaches, and other employees of the organization, other participants, sponsoring agencies

sponsors, advertisers, and if applicable, owners and lessors of premises used to conduct the event, all of which are

hereinafter referred to as “releases”, from demands, losses or damages on account of injury, including death or damage

to property, caused or alleged to be caused in whole or part by the negligence of the release or otherwise.

 

5. If any sessions are canceled for any reason, whatsoever, Big Wheel will reschedule at an available time. If no time

is made available, then the portion of the session unused shall be refunded.

 

I have read the above waiver and release and understand that I have given up substantial rights by signing it

voluntarily. I also agree to abide by all rules of the Big Wheel Indoor Sports Leagues as outlined in the application,

flyer and/or B.W.F.R.H.L rulebook.

 

DATE: _________________________SIGNATURE _______________________________________________________

IF MINOR, PARENT OR LEGAL GUARDIAN SIGNATURE REQUIRED___________________________________________