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Please complete the pre-registration form below for this years Hockey program.

PLEASE SUBMIT A FORM FOR EACH CHILD YOU ARE REGISTERING

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Yes
No

* Required

Rev 10/1/2017
SIIHA CLINIC PARTICIPATION - TERMS AND CONDITIONS
WAIVER OF LIABILITY, RELEASE, ASSUMPTION OF RISK & INDEMNIFYING AGREEMENT
For and in consideration of participant's registration with STATEN ISLAND ICE HOCKEY ASSOCIATION, Inc., its Affiliate, Local association and
member team (hereinafter SIIHA) and being allowed to participate in SIIHA events and member team activities, the parent(s) or legal
guardian(s) of participants relinquish any and all liability for and cause of action for personal injury, property damage or wrongful death
occurring to participant arising out of participation in SIIHA events or member team activities or the sport of ice hockey, or and activities
incidental thereto, wherever 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 may have are hereby relinquished and the participant (or parent(s)/guardian(s) does (do) so on
behalf of my/our and participant's heirs, executors, administrators and assigns.
Participant and/or participant's parent(s)/guardian(s) acknowledge, understand and assume all risks inherent in ice hockey and any member
team activities, and understand that said sport and activities involve risks to participant's person including bodily injury, partial or total disability,
paralysis, and death, and damages which may arise there from 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 "releases" identified below. It is further acknowledged that
there may be risks and dangers not known to us or are not reasonably foreseeable at this time.
Participant and/or participant's parent(s)/guardian(s) acknowledge. understand and assume the risks, if any, arising from the conditions and
use of ice hockey rinks and related premises and acknowledges and understands that included within the scope of this waiver and release is
any cause of action, 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 releases, or negligent supervision or instruction
by releases.
It is the purpose of this agreement to exempt, waive and relieve releases from liability for personal injury, property damage, and wrongful death
caused by negligence, including the negligence, if any, of releases.
"Releases" including Staten Island Ice Hockey Association, Inc., its Affiliate Associations, Local Associations, member teams, event hosts, other
participants, coaches, officials, sponsors, advertisers. Owners and operations of the premises used to conduct any event and each of them, their
officers, directors, agents and employees.
Participant or participant's parents(s)/guardian(s) agree if any claim for participant's personal injury or wrongful death is commenced against
releases, he/she shall defend, indemnify and save harmless releases 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.
I understand that the SIIHA requires the use of all protective hockey equipment for all ages at all times and that the failure to use same could
result in a serious injury (It is the Players, Parents, and/or Guardian's responsibility to insure compliance not the SIIHA). With full
understanding of the risks involved, I voluntarily take all the risks involved in my actions. I further agree to waive, release, absolve, indemnify
and hold harmless the CITY OF NEW YORK and any of their agencies or representatives, SIIHA (d/b/a Staten Island Ice Hockey Association),
SIIHA, and the ICE ARENA, their officers, organizers, referees, employees, supervisors, instructors, and participants from any and all claims
arising out of any injury that my ward or I might sustain while playing or watching hockey in any SIIHA program. I further understand that my
ward(s) and/or I are participating at our own risk and that Staten Island Ice Hockey Association and/or NYC/DYCD, if applicable, will provide a
limited secondary insurance, any and all medical and/or liability claims made, against any of the above as a result of my ward(s) and/or my
involvement with the SIIHA program will be limited to that coverage only and will not exceed its maximum limitations. I have read, understand,
and agreed to abide by the liability limitations above.
Participant and/or participant's parent(s)/guardian(s) acknowledge that they have been provided and have read the above paragraphs and
have not relied upon any representations of releases, 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. I will allow an electronic attendance
sheet or club identification card to be generated with my child or ward's signature and/or printed name on it. I will allow an electronic
authorization signature sheet with my name and/or my child or ward's printed name on it in order to be reproduced or used in conjunction
with his or her activities when required when he/she participates in an organization program or event. I also will allow an electronic picture
to be affixed to my child or ward's demographic record or club identification card with his or her name or signature indicated. I will allow
myself, family member, friend or child to be identified and/or photographed if used in any activity, promotion or advertisement for the
organization, event, or program he or she is participating in.
I have read this form and do acknowledge its contents. I have submitted an electronic registration form previously which indicates I have
given my permission for my child or ward to participate in the SIIHA program. By signing the reverse side of this new form (printed
registration form), I do hereby duplicate my permission for my child or ward to participate in what is generally considered a harmless or a
low risk of injury event but may be perceived by others as hazardous.
I hold harmless the aforementioned Organization indicated on the reverse side of this form during any of its: Youth Activities, Tournaments,
Programs, and Games. I also will allow an electronic attendance sheet or Club Identification card to be generated with my child or ward's
signature and printed name on it when he participates. I also allow an electronic authorization signature sheet with my name to be used in
conjunction with his activities when required. I also will allow a picture of my child to be used by the SIIHA for advertising, website, ward's
demographic record or Club Identification card with his or her signature may be affixed.
PARENT OR GUARDIAN'S SIGNATURE IS ON REVERSE SIDE
OR
PARENT OR GUARDIAN'S SIGNATURE IS ON ELECTRONIC REGISTRATION FORM
(If Participant is 17 years of age or younger)

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