Register for the Flint Inner City Youth Hockey Program

Registration

"*" indicates required fields

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This field is for validation purposes and should be left unchanged.

Name of Participant*

First Last

Date of Birth*

Gender*

Male

Female

Name of Parent of Guardian*

First Last

Current Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Secondary Phone

Email*

Please list two additional contacts in case of an emergency.

Emergency Contact #1 Name*

First Last

Emergency Contact #1 Relationship to Participant*

Emergency Contact #1 Phone*

Emergency Contact #2 Name*

First Last

Emergency Contact #2 Relationship to Participant*

Emergency Contact #2 Phone*

Does the participant have any special needs or medical concerns? If so, please describe below.

Is the participant a resident of the City of Flint?*

Yes

Will you need weekly free transportation to the program?*

Yes

A parent or guardian above the age of 16 will be in attendance each week with the participant?*

Yes

PARTICIPANT AGREEMENT

I am the parent/guardian of the above-named participant who is under 18-year of age and am fully competent to sign this Agreement. By signing this agreement I give permission for the Participant to participate in the activities of learning the fundamentals of hockey and agree to the following:

Liability Limit

I understand that the Flint Inner City Youth Hockey Program aims to teach youth the fundamentals of ice hockey. Participants will engage in physical recreation and education such as ice skating, shooting, stopping and passing the puck, blocking shots, teamwork, positive attitudes, good sportsmanship. Activities will take place at 3501 Lapeer Rd., Flint, MI 48503.

I acknowledge that there are risks involved in activities of ice hockey. Participant to hazards or risks may result in Participant’s illness, injury or death and I understand and accept the nature of such hazards and risks.

In consideration of Participant being permitted to participate in any Flint Inner City Youth Hockey Program activity, I hereby release its program, directors, staff, volunteers and any other representatives from any and all liability to Participant, Participant’s personal representatives, estate geris, next of kin and assigns for any and all claims and causes of action for loss of or damage to Participant’s property and for any and all illness or injury to Participant’s person, including his/her death, that may result from the hazards and risks inherent in Participant’s participation in the Activity, including the hazards and risks described above.

Participant's Name*

Parent/Guardian Initials*

Indemnification

I further agree to indemnify and hold harmless the Flint Inner City Youth Hockey Program directors, staff and volunteers and its governing boards, officers, employees, agents, and other representatives from liability for the injury or death of any person(s) and damage to property that may result from Participant’s negligent or intentional act of omission while participating in the described Activity.

Parent/Guardian Initials*

Assignment of Rights

I hereby grant permission for the Flint Inner City Youth Hockey Program to disseminate through broadcasting or publishing, pictures, videos, and/or voice recording taken during any hockey related activities in which the Participant appears for promotional purposes at the discretion of the program. Additionally, I hereby assign to the Flint Inner City Youth Hockey Program a nonexclusive right to use all photos of the Participant during the program in connection with any activities, including but not limited to public relations, publishing, and fundraising. Participant shall not be entitled to any compensation for the use of any Participant’s photos by the Flint Inner City Youth Hockey Program.

Parent/Guardian Initials*

Authorization for Emergency Treatment

If you cannot reach me in the event of an emergency, I give permission to seek the treatment necessary for the health and safety of my child.

Parent/Guardian Initials*

Signature*

Name*

First Last