First Name:_________________Last Name:____________________
D.O.B.______ / _____/ ______
Parent or Guardian (If player is under 18 years of age)___________________________________
Home Phone ( )_____________________Cell Phone ( )____________________
I (parent or guardian if applicable) hereby give my consent and agree to release, indemnify, and hold harmless the Las Vegas Roller Hockey Center,Inc., and all personnel including referees, staff management, scorekeeper and owners from any claim arising from personal injury or property damage to the named individual. I understand that Las Vegas Roller Hockey Center, Inc. does not carry insurance to cover participants in the activity of which I am registered. I understand the hardness of the playing surfaces and dasher-boards, and the roughness of the sport. I grant Las Vegas Roller Hockey Center, Inc. the right to photograph and /or video the players in participation in Roller Hockey activities, and to use the photographs or video in future brochures and, or commercials.
GUARANTEE OF COMPLIANCE TO RULES OF THE LAS VEGAS ROLLER HOCKEY CENTER
In the event of any dispute arising between the undersigned agrees to abide with all the Las Vegas Roller Hockey Center rules, policies,and Officials. Las Vegas Roller Hockey Center reserves the right to impose restrictions and or penalties as a result of noncompliance with Las Vegas Roller Hockey Center rules and policies. Copies of the rules and policies are available at the request of the undersigned in the office of Las Vegas Roller Hockey Center, Inc.
ALL FEES ARE NON-REFUNDABLE!
I (parent or guardian of the participant, if a minor), do hereby authorize the coaches, assistants, staff or parents of team members to act in capacity of activity supervisors as agents for the undersigned to consent to medical, surgical, or dental examination or treatment, etc...in cases of emergency. I hereby authorize treatment and, or care of registered player in any hospital and by medical physician. If there is an emergency and I cannot be reached, please contact the following emergency name and phone number, (family, friend or neighbor).
In case of emergency contact__________________ Phone ( ) ________________
Family Doctor _________________________________ Phone ( ) ________________
Health Insurance Co. Name________________________ Policy # ________________
Please read all of the above before you sign.
Signature of Player (if 18 or older) _________________________________ Date ______
Signature of Parent (if player is under 18 years of age) _______________________
Las Vegas Roller Hockey Center, Inc.
800 Karen, Las Vegas, NV 89109
www.lasvegasrollerhockey.com Phone (702) 349-6526