Twhs Inline Registration Form

Houston High School Inline Hockey League

Season Registration: _________________ Team: _______________________ Player Information Name: Last:

First:

AAU Membership#

Middle:

Jersey #

Street:

Phone:

City:

State:

Zip:

DOB: School District: . Grade: email address for parent/guardian:___________________________________________________________________ e-mail address for player (if different):________________________________________________________________ Parent/Guardian Information Parent/Guardian Name:

Home Phone:

Work Phone _______________________________________ Cell Phone ___________________________________ Emergency, contact: Name:

Phone:

Physician:

Relation: Phone:

Any Medical Problems?

Minimum Equipment Requirements All participants must have and use their own skates, hockey stick, and protective equipment as per the current USARS/AAU rules. Indemnification Agreement I hereby release, discharge and/or otherwise indemnify the Houston Inline Hockey League, its employees and associated personnel, including the owners of the arenas and facilities utilized by the programs, against any claims by or on behalf of the registrant as a result of the registrant’s participation in the program and/or being transported to or from the same, which transportation I hereby authorize. As the parent/guardian of the above named player, I hereby give consent for emergency medical care prescribed by a duly licensed doctor of medicine. This care may be given under whatever conditions are necessary to preserve the life, limb or well being of dependent. I also give consent for any photograph’s taken during participation events to be used for publicity purposes and other types of publicity.

I hereby give my approval and consent to this Indemnification Agreement.

Name:

Signature: Parent/Legal Guardian (Please Print)

Date: