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:

  1. 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
  2. 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
  3. 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
  4. 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