FORT ZUMWALT WEST HOCKEY CLUB 2013 SUMMER PROGRAM

This form gives permission for ______________________________________________ to participate in the 2013 SUMMER PROGRAM sponsored by the Fort Zumwalt West Hockey Club (FZWHC). Please carefully read the following statements below, fill in the required information, date and sign this form. By signing this form, you are releasing the FZWHC, and their respective officers, directors, agents, members, employees, coaches, representatives and volunteers from any claims for liability, personal injury, death, or property loss incurred in connection with the 2013 Summer Program. You are also giving the Released Parties, their officers, directors, agents, members, employees, coaches, representatives, and volunteers permission to seek whatever medical attention we deem necessary in the event of an emergency. I agree (on behalf of myself and/or my minor child) that the Released Parties, together with their officers, directors, agents, members, employees, coaches, representatives and volunteers, shall not be responsible for and are hereby released from any claims or liability for any personal injury, death, or property loss incurred in connection with the 2013 Summer Program. I also authorize the Released Parties to seek emergency medical treatment on behalf of me and/or my minor child in the event that such treatment is deemed necessary or appropriate by the Released Parties and release the Released Parties from any liability related to that decision or treatment. I understand that participation by me and/or my minor child in the 2013 Summer Program is voluntary. I understand that the Released Parties may not carry insurance to cover any injury, loss or other damages that may occur during my and/or my minor childs participation in the 2013 Summer Program. I understand that ice hockey is a dangerous sport and assume all risks of injury, loss or other damages incidental to the game of ice hockey, including injury or damage caused by pucks, sticks, ice, boards, equipment or other players. I understand that the Fort Zumwalt West Ice Hockey Club Summer Program is a training and fitness program. I understand that there will be weight lifting training involved as a part of the fitness program. I understand that weight lifting can be a dangerous if not done properly. I assume all the risks of injury involved with a weight training program. I understand that the Fort Zumwalt West Ice Hockey Club Summer Program is a training and fitness program. I understand that there will be dry-land training as a part of the fitness program. I understand that dry-land training involves cardiovascular and cross training type exercises. I understand this type of

training has inherent risks of injury. I assume all risks of injury involved with the dry-land training program. It is also agreed to that by signing below it is understood that any injured player associated with Fort Zumwalt West Hockey Club WILL NOT BE ALLOWED TO RETURN TO ACTIVE PLAYING STATUS UNTIL A WRITTEN CLEARENCE LETTER FROM HIS ATTENDING PHYSICAN IS PRESENTED TO THE CLUB BOARD OF DIRECTORS. When the proper documentation is delivered: the players coach/coaches will be notified that the players return to play status has been satisfied. The direction of the players medical doctor is final. It is also understood that the coaches on the ice have the authority to remove a player from active status if they feel an injury has been sustained. It is also understood that the Fort Zumwalt West Hockey Club is held harmless for any reoccurrence or continued repercussions from any pre-existing medical condition the player may have had prior to the start of the 2013 Summer Program.

DATE: ________________ Signature:_____________________________________ Print signers name: _______________________________ Adult Please circle one: Participant Parent Guardian

*************************** Parent/Guardian must sign for minor participants! ****************************** EMERGENCY/PARENT/GUARDIAN CONTACT:__________________________________________________________________________________________ __ RELATIONSHIP: ________________________________________________________________________________________ Phone:___________________________________________ Work HEALTH INSURANCE CARRIER AND NUMBER: _____________________________________________________________________ PLEASE PRINT Please circle one: Home Cell