Please provide the following information:

Name
Street Address
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
Cell Phone
Fax
E-mail
Date of Birth
Age
Position	Left Wing Right Wing Center Left Def Right Def Goalie

 

Participant Statement of Responsibilities & Agreement 

Ice hockey is a physically active sport and participation may result in physical injuries.  Injuries may result in minimal or severe damage to ones body: (i.e. bruises, cuts, broken bones, injuries to eyes and teeth among other things).  Injuries may include catastrophic consequences, including but not limited to permanent paralysis or even death.   

I fully understand the personal and family risks associated with participation in ice hockey.  I also understand it to be my responsibility to take all safety steps by utilizing the appropriate equipment necessary to keep myself protected.  I will follow the rules of hockey and play within the spirit of the rules.  I will only use my body and equipment for purposes provided by the rules.  I will not check any other player and I will avoid aggressive acts and keep my emotions under control at all times.  I agree to have an annual physical to validate my health and fitness.    

I understand and agree that I participate in this sport and with this group at my own risk.

 I further understand ice hockey players are legally liable for injuries to others due to “reckless disregard” for safety to others.         

 I will share this agreement and information with my spouse and family members.

Check to Agree 

Medical Statement

 

Skating at my own risk, I understand the dangers of the sport and the need to have the appropriate medical insurance coverage.  I also acknowledge there are no forms of insurance coverage provided to me by anyone or any organization through my participation with this organization.

 

I accept full responsibility to provide all insurance coverage desired and I will provide primary and catastrophic medical insurance in the event of injury.  I further agree to notify the organization if the status of coverage changes.  I agree not to participate without having insurance coverage in place.  My insurance information is provided below:

 

Name of Insurance Provider  

Policy Number  

Other  

  

 

Waiver, Hold Harmless and Indemnification Agreement

 

I am aware that efforts are being made on my behalf by this organization to provide a positive venue for ice hockey.  It is with this understanding and full knowledge of the risks of playing ice hockey, to me and the potential affects to my family, in the case of injury, that I unconditionally waive my/our rights of recovery from this organization, its affiliates, organizers, sponsors, successors, assigns, heirs, directors, officers, administrators coaches and managers.

 

In consideration for the opportunity to participate, I hereby understand and agree, it is a condition of participation, that I unconditionally release, forever discharge, hold harmless and indemnify this organization, its affiliates, organizers, sponsors, successors, assigns, heirs, directors, officers, administrators, coaches and managers from any and all liability and or claims foreseen or unforeseen surrounding my participation with this organization as an ice hockey player or otherwise.  I agree this Waiver, Hold Harmless and indemnification, will extend to the Michigan Sting Hockey Club and its organizers, co-organizer, other organizations partnered or in support of our efforts and activities. 

 

This Agreement, Waiver, Hold harmless and Indemnification Agreement apply to any and all activities, events or outings wherever they are held.  The conditions within the above, apply to affiliates who are either directly or indirectly involved in supporting MSHC activities, events or outings.

 

I fully accept and agree to all conditions set forth.

Check to Agree