Western Mass Vipers

Subscribe to our Newsletter

2018 15U Player Information Form

PLAYER INFORMATION

Last Name:

First Name:

Middle Inital:

Street:

City:

State:

Zip Code:

Home Phone:

Birthdate:

Grade:

2017-2018 USA Hockey Registration Number:

Position:

Weight:

Height:

Shot:

Hockey Jersey Size (adult sizes):

Preferred Jersey Number - list 4 choices in order of preference:

T-Shirt Size:

Gym Short Size:

PARENT/GUARDIAN #1

Firstname:

Lastname:

EMail:

Home Phone:

Work Phone:

Cell Phone:

PARENT/GUARDIAN #2

Firstname:

Lastname:

Email:

Home Phone:

Work Phone:

Cell Phone:

MEDICAL/EMERGENCY CONTACT INFORMATION

Emergency Contact:

Phone:

Relationship to Player:

Insurance Carrier:

Policy #:

WAIVER INFORMATION

In consideration of Western Mass Vipers Youth Hockey Association, Inc. accepting the participant for participation in its skating/hockey programs and/or activities I, the parent/legal guardian of the participant, a minor, agree and acknowledge that: (1) I and the participant will abide by the rules and/or bylaws of: USA Hockey, Inc.; Massachusetts Hockey, Inc; and the Western Mass Vipers Youth Hockey Association, Inc; (2) I recognize the possibility of injury associated with hockey and related team activities. I hereby release, discharge and/or otherwise indemnify Western Mass Vipers Youth Hockey Association, Inc and sponsors, their employees, and associated personnel including directors, coaches and managers, against any claim by or on behalf of the participant as a result of the participant’s participation in the programs and/or activities Western Mass Vipers Youth Hockey Association, Inc, including but not limited to hockey activities, off-ice team activities, day or overnight camps, indoor and outdoor physical activities including swimming, weight training, other active sports, and/or being transported to or from the same, which transportation I hereby authorize.

Consent for Medical Treatment (Minor)
As parent or legal guardian of the above-named participant, I hereby give my consent for emergency medical care prescribed by a duly licensed Doctor of Medicine or Doctor of Dentistry. This care may be given under whatever conditions are necessary to preserve life, limb, or well-being of my child/ward.

Waiver of Liability, Release Assumption of Risk & Indemnity Agreement
It is the purpose of this agreement to exempt, waive and relieve release from liability for personal injury, property damage, and wrongful death, including if caused by negligence, including the negligence, if any, of releasees. “Releasees” include USA Hockey, Inc., its affiliate associations, local associations, member teams, event hosts, other participants, coaches, officials, sponsors, advertisers, and each of them, their officers, directors, agents and employees. For and in consideration of the undersigned participant’s registration with USA Hockey, Inc., its affiliates, local associations and member teams (all referred to together as USAH) and being allowed to participate in USAH events and member team activities, participant (and the parent(s) or legal guardian(s) of participant, if applicable) waive, release and relinquish any and all claims for liability and cause(s) of action, including for personal injury, property damage or wrongful death occurring to participant, arising out of participation in USAH events, member team activities, the sport of ice hockey, and/or activities incidental thereto, whenever or however they occur and for such period said activities may continue, and by this agreement any such claims, rights, and causes of action that participant (and participant’s parent(s) or legal guardian(s), if applicable) may have are hereby waived, released and relinquished, and participant (and parent(s)/ guardian(s), if applicable) does(do) so on behalf of my/our and participant’s heirs, executors, administrators and assigns.

Participant (and participant’s parent(s)/guardian(s), if applicable) acknowledge, understand and assume all risks relating to ice hockey and any member team activities, and understand that ice hockey and member team activities involve risks to participant’s person including bodily injury, partial or total disability, paralysis and death, and damages which may arise therefrom and that I/we have full knowledge of said risks. These risks and dangers may be caused by the negligence of the participant or the negligence of others, including the “releasees” identified below. These risks and dangers include, but are not limited to, those arising from participating with bigger, faster and stronger participants, and these risks and dangers will increase if participant participates in ice hockey and member team activities in an age group above that which participant would normally participate in. I/We further acknowledge that there may be risks and dangers not known to us or not reasonably foreseeable at this time. Participant (and participant’s parent(s)/guardian(s), if applicable) acknowledge, understand and agree that all of the risks and dangers described throughout this agreement, including those caused by the negligence of participant and/or others, are included within the waiver, release and relinquishment described in the preceding paragraph. I/We agree to abide by and be bound under the rules of USA Hockey, including the By-Laws of the corporation and the arbitration clause provisions, as currently published. Copies are available to USA Hockey members upon written request.

Participant (and participant’s parent(s)/guardian(s), if applicable) acknowledge, understand and assume the risks, if any, arising from the conditions and use of ice hockey rinks and related premises and acknowledge and understand that included within the scope of this waiver and release is any cause of action (including any cause of action based on negligence) arising from the performance, or failure to perform, maintenance, inspection, supervision or control of said areas and for the failure to warn of dangerous conditions existing at said rinks, for negligent selection of certain releasees, or negligent supervision or instruction by releasees.
Participant (and participant’s parent(s)/guardian(s), if applicable) agree if any claim for participant’s personal injury or wrongful death is commenced against releasees, he/she shall defend, indemnify and save harmless releasees from any and all claims or causes of action by whomever or wherever made or presented for participant’s personal injuries, property damage or wrongful death.

Participant (and participant’s parent(s)/guardian(s), if applicable) acknowledge that they have been provided and have read the above paragraphs and have not relied upon any representations of releasees, that they are fully advised of the potential dangers of ice hockey and understand these waivers and releases are necessary to allow amateur ice hockey to exist in its present form. Significant exclusions may apply to USA Hockey’s insurance policies, which could affect any coverage. For example, there is no liability coverage for claims of one player against another player. Read your brochure carefully and, if you have any questions, contact USA Hockey or a District Risk Manager.

I/we agree with the above *

* indicates required fields

OUR SERVICES

LOCAL SPORTS

ELITE

2018 15U Player Information Form