Moorestown Youth Street Hockey Association (MYSHA) Registration Form

Moorestown Youth Street Hockey Association (MYSHA) Registration Form

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PARENT CONTACT INFORMATION

PARENTS/GUARDIANS:
(LAST NAME, FIRST NAMES)
ADDRESS:
HOME PHONE: / EMERGENCY PHONE:
E-MAIL ADDRESS:

Waiver/Release/Medical-Authorization/Conduct

I, the parent of ______, in consideration for my child being allowed to participate in any and all MYSHA activities, including but not limited to tryouts, practices, games and/or events, acknowledge that I have read, understood, and agree to the terms of this waiver/release and medical authorization. I acknowledge that there are risks connected with allowing my child to participate in MYSHA activities, including but not limited to, those associated with weather conditions, playing conditions, equipment, facilities, other participants, and the possibility of collisions, any or all of which could result in injury or even death, and I acknowledge and assume them by allowing my child to participate. I assume all risks and hazards incident to such participation, as well as the risks and hazards incidental to and arising from the transport of my child to and from the activity.
I release and discharge MYSHA, its officials, organizers, participants, members, parents, owners, sponsors and lessors of the premises used to conduct the MYSHA activities, volunteers, equipment manufacturers and persons transporting my child to and from MYSHA activities, for any and all loss, liability, damage, cost, expense, action, suit and demand what so ever in law or equity arising from, based upon or leading to personal injury or death to, or damage to or loss of property of my child or me, sustained in connection with my child’s participation in MYSHA activities. I represent that my child is physically able to participate in MYSHA activities, and is not subject to any medical condition that may pose a risk of harm to others. If my child requires any special medication, or has any medical conditions, I have listed it/them below. In case of an emergency need for medical treatment, I authorize MYSHA to transport my child under a legal physician, and administer treatment. As a PARENT I will cheer for ALL the players on each Team and demonstrate good sportsmanship. I will be supportive when my child/team is successful OR struggling and whether the Team wins or loses. I will show respect for the Referees, opposing fans and the other fans. As a COACH I will model good sportsmanship and will enact MYSHA’s Fair Play Policy.
PARENT SIGNATURE: / DATE:

PLAYER INFORMATION

PLAYER’S LAST NAME, FIRST NAME:
MEDICATIONS & MEDICAL CONDITIONS:
BIRTH DATE (MM/DD/YY): / For Street: AGE ON JANUARY 1ST NEXT YEAR:
HEALTH INS: / For Roller: AGE ON JANUARY 1ST THIS YEAR:
DIVISION: / [ ] Half Pint (Ages 5-6) / HEIGHT/WEIGHT: Average Above Average
[ ] Mite (Ages 7-9) / JERSEY NUMBER: ____, ____, ____
[ ] Bantam (Ages 10-12)
[ ] Cadet (Ages 13-15) / [ ] PLAYER IS A GOALIE

[ ] Cruiser (Ages 16-18)

VOLUNTEER OPPORTUNITIES

I’LL VOLUNTEER TO COACH: / [ ] Half Pint / [ ] Mite / [ ] Bantam / [ ] Cadet
I’LL VOLUNTEER FOR: / [ ] Referee / [ ] Team Mom / [ ] MYSHA Admin Position

PAYMENT

Include CASH or CHECK Payable to MYSHA : $60 Ages 7-15 or $35 Ages 5-6
Family Discount: 2 Children - $90, 3 children $120, 4 Children $150
AMOUNT: / [ ]CHECK #: / [ ] CASH
PLAYER EVALUATION SCORES (Filled-In by Evaluators)
(1) ____/____ / (2) ____/____ / (3) ____/____ / AVG ____/____ / FINAL ______