give blood play hockey registration forms 2011

8/6/2019 Give Blood Play Hockey Registration Forms 2011

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Dear Hockey Coaches, Managers, Captains, Players and Friends:

You, your team and your entire family are invited to join us for the fifth annual Give Blood Play Hockey InlineHockey Charity Tournamenta serious hockey tournament with a serious purpose! While teams will becompeting on the rinks for their spot on the perpetual trophythe Blood Cup, theres plenty of off-rink fun fothe whole family. Proceeds from the weekend long event will benefit the Childrens Hospital of Orange County(CHOC); plus well be giving the gift of life through your valuable Blood Donations.

This years tournament will be held October 21st 23rd, at The 949 Roller Hockey Center in Irvine and will hosdivision teams from Tyke to Adult, Scholastic, Mens and Womens, and beginner through professional.

This year promises to be another great tournament for all teams. Inquiries have been steadily pouring in fromacross the southland. And Good News! This years fees are the same as last years! Your tournament entryfee is tax deductible, and if you register at least two adults to give blood you can apply a $25 discount to yourregistration fees. We expect this to be a sold-out event, so please take advantage of early registration andsign-up today! SPACE IS LIMITED TO 95 TEAMS, SO PLEASE RESPOND IMMEDIATELY BY E-MAIL TOGUARANTEE YOUR SPOT.

ONLINE REGISTRATION AND PAYMENT NOW AVAILABLEwww.tinyurl.com/GBPH-REG-n-PAY

In addition to some competitive hockey, the tournament features fun events for the whole family. You wontwant to miss our skills competition, a wheelchair hockey exhibition, rink-side vendors, games and displays alin a carnival-like setting. Attendees can also buy raffle tickets for chances to win donated high-ticket itemshockey equipment; and much, much more! New events and sponsors are being added regularly if you oyour company would like to participate, please contact us.

GIVE BLOOD. GIVE LIFE. Its Hockey With A Heart!The Bloodmobiles also will be at the event so attendees cangive a very special donation of another kindtheir blood!Plan to take some of your valuable time while attending andBe A Hero and Give Blood. It doesnt hurt. Honest!

Please review the information included with this packet; it describes the tournament rules, gives details aboutthe format and different levels of play, registration information, and the required paperwork to register yourteam. It also describes the incredible work being done by our volunteers to help our beneficiary organizationssuch as CHOC and the children that this event will support.

If you have registration questions, please call us at (714) 330-1602, or send an e-mail [email protected]. Most importantly, register soon to reserve your space in the most important hockeytournament of the year!

Thank You!The GBPH Organizing Committee www.GIVEBLOODPLAYHOCKEY.org

October 21-23, 2011The 949 Roller Hockey Center - Irvine, CA

PLEASE JOIN US!
http://www.tinyurl.com/GBPH-REG-n-PAYhttp://www.tinyurl.com/GBPH-REG-n-PAYhttp://www.tinyurl.com/GBPH-REG-n-PAYmailto:[email protected]:[email protected]:[email protected]://www.tinyurl.com/GBPH-REG-n-PAY


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Give Blood Play Hockey

Inline Hockey Charity TournamentSerious Hockey for a Serious Cause

October 21-23, 2011

949 Roller Hockey Center, Irvine, California

The 5th annual Give Blood Play Hockey Inline Hockey Charity Tournament (GBPH) is an Irvinebased, family oriented event that will once again draw thousands of hockey players and fans to aweekend long, carnival like atmosphere designed to showcase hockey talent while giving back to thecommunity. Founded in 2007 by then Mater Dei High School senior and hockey player Mary Quayle,this tournament began as a service project motivated by her desire to pay back to the community theblood donated to her late grandfather and pay forward to children and those in need in ourcommunity.To date, the GBPH tournament has collected over 600 pints of life saving blood and donated over$125,000 to CHOC Childrens Hospital with a pledge of $100,000 to build an Oncology Patient Roomin the new wing of the hospital scheduled to open in 2013. Weve hosted hundreds of hockey teams,seen some crazy skills in the Skills Competition, and raffled off some amazing prizes including Ducksand Kings tickets, hockey equipment, weekend getaways, helicopter rides and more. We have alsohad the pleasure of seeing CHOCO Bear, Ryan Getzlaf, Bobby Ryan, and Kyle Chipchura, WildWing, the Power Players and other distinguished guests during our first 4 tournaments.This year we are raising the bar again in our blood donation and fundraising efforts. We will alsohave the athletes from the Rancho Wheelchair Hockey League playing an exhibition game, willcelebrate the continued recovery of one of our own hockey players, Casey Strale, who was diagnosedwith cancer during our 3rd tournament and is back playing at the top of his game, and find moreways to pay it forward for all the children served at CHOC Childrens Hospital.

To learn more about this event or register a team, please contact us by email at:[email protected], visit our web site atwww.GIVEBLOODPLAYHOCKEY.orgor join us on Facebook at:http://www.facebook.com/pages/Give-Blood-Play-Hockey/114966515217989

For more information about how you can participate or help in our community cause, please contact us:

949 Roller Hockey Center

3150 Barranca ParkwayIrvine, CA 92606-5202(949) 559-9949www.949rollerhockey.com

Eddie Limbaga, [email protected]

Event ContactsCorporate Sponsors:Dale Quayle (714) 330-1602Food Vendors/Blood Donations:

Peggy Quayle (714) 307-1980Fundraising/Raffle/SilentAuction:Traci Strale 949-910-9886Media & Marketing:Raquel Perez(949) 274-2536Non-food Vendors/Exhibitors:Julie Ruff (717) 318-7788Team Registrations:Julie Ruff (714) 318-7788Rita Dwyer (714) 900-1775

For more information, send email [email protected] call(714) 330-1602

Visit our web site:GIVEBLOODPLAYHOCKEY.org
http://../Local%20Settings/Temporary%20Internet%20Files/Local%20Settings/Temporary%20Internet%20Files/Local%20Settings/Temporary%20Internet%20Files/Content.Outlook/HQ6I2HYJ/[email protected]://../Local%20Settings/Temporary%20Internet%20Files/Local%20Settings/Temporary%20Internet%20Files/Local%20Settings/Temporary%20Internet%20Files/Content.Outlook/HQ6I2HYJ/[email protected]://www.givebloodplayhockey.org/http://www.givebloodplayhockey.org/http://www.givebloodplayhockey.org/http://www.facebook.com/pages/Give-Blood-Play-Hockey/114966515217989http://www.facebook.com/pages/Give-Blood-Play-Hockey/114966515217989http://www.facebook.com/pages/Give-Blood-Play-Hockey/114966515217989mailto:[email protected]:[email protected]:[email protected]://www.facebook.com/pages/Give-Blood-Play-Hockey/114966515217989http://www.givebloodplayhockey.org/http://../Local%20Settings/Temporary%20Internet%20Files/Local%20Settings/Temporary%20Internet%20Files/Local%20Settings/Temporary%20Internet%20Files/Content.Outlook/HQ6I2HYJ/[email protected]


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Heres the 411 on Registering Your Team

1. All Team Registrants Must Complete and Submit:TEAM REGISTRATION INFORMATION, page 1 and 2.Complete these two forms and payment for registering your teamSubmit completed forms to the contacts listed below before Friday, October 14, 2011

OFFICIAL ROSTERComplete this form and submit when checking in your team at the event

2. All Players Must Complete and Submit:

949 WAIVER FORM (attached with email or by request from the 949 or on site)Complete this form(s) and submit when checking in your team at the event

*PLAY *GIVE *DONATE *SAVE!Teams registered by September 23rd pay *$450, after the 23rd he fee increases to $500. All registrationsmust be complete and paid in full by October 14th! Sign up two blood donors and save $25 on your fees.Pay fee on line atwww.tinyurl.com/GBPH-REG-n-PAY


Submit Your Completed Registration Packet To:


If you, your team, or your Company, would also like to make a donation to this event, pleasealso include the Sponsor Form included with this packet - No Donation is Too Big or TooSmall to Help!

October 21-23, 2011The 949 Roller Hockey Center - Irvine,CA

949 Roller Hockey Center3150 Barranca ParkwayIrvine, CA 92606(949) 559-9949Fax: 949 559-9948
http://www.tinyurl.com/GBPH-REG-n-PAYhttp://www.tinyurl.com/GBPH-REG-n-PAYhttp://www.tinyurl.com/GBPH-REG-n-PAYhttp://www.tinyurl.com/GBPH-REG-n-PAYhttp://www.tinyurl.com/GBPH-REG-n-PAYhttp://www.tinyurl.com/GBPH-REG-n-PAYhttp://www.tinyurl.com/GBPH-REG-n-PAYhttp://www.tinyurl.com/GBPH-REG-n-PAYhttp://www.tinyurl.com/GBPH-REG-n-PAYhttp://www.tinyurl.com/GBPH-REG-n-PAYhttp://www.tinyurl.com/GBPH-REG-n-PAYhttp://www.tinyurl.com/GBPH-REG-n-PAY


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TEAM REGISTRATION INFORMATION Page 1 of 2

Team Name

Coach/Manager Name

Coach/Manager Address

City State Zip

Home Phone Cell Phone

EMAIL (required)

Please complete the following registration information by checking the blank next to the division and level ofplay for your team (type in X). Please complete one form for each team you wish to register. Age cut off fo

the club division is based on the players age as of December 31st, 2011. Please see the roster guidelineswith the enclosed tournament rules and regulations.

Club Division (Need to convert Age to Club Division? See our Tournament Rules to learn more.)

Age Level 8U 10U 12U 14U 16U 18U Adult

Skill Level Beginner Intermediate Advanced

Team Gender Male Female Co-Ed

Scholastic Division

Jr. High Varsity JVA

High School Varsity JVA JVB JVC

College Div. 1 Div.2

What Division did this Team play in the 2010-11 Season (or Last)?

What is this Teams Home Rink? (enter name of rink)

Any Comments about this Team?

MORE REGISTRATION DETAILS ON NEXT PAGE

October 21-23, 2011The 949 Roller Hocke Center - Irvine CA
http://www.tinyurl.com/GBPH-REG-n-PAYhttp://www.tinyurl.com/GBPH-REG-n-PAYhttp://www.tinyurl.com/GBPH-REG-n-PAYhttp://www.tinyurl.com/GBPH-REG-n-PAY


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TEAM REGISTRATION INFORMATION Page 2 of 2

Team Name

Age Level / Division

PLAY. GIVE. DONATE. SAVE!The tournament entry fee is tax deductible, and if you register at least two adults to give blood you can apply a$25 discount to your registration fees. Pay early and save $50! Register online or use this form.

ONLINE REGISTRATION AND PAYMENT SITE: www.tinyurl.com/GBPH-REG-n-PAY

Select your tournament entry fee:

$450 PER TEAM Early registration by September 23, 2011

$500 PER TEAM Registration after September 23, 2011

$25 PER TEAM Discount for Two Blood Donations

$ Your Team Fee $

DONORS:

Blood Donor #1 Name Age Phone

Blood Donor #2 Name Age Phone

Yes we would like to donate a gift basket and get free raffle tickets (see next page)

Yes we would like to donate baked goods and get free raffle tickets (see next page)

All fees are to be paid by credit card, cash, check, or money order and are due by Oct. 14, 2011. Please makechecks payable to: CHOC Foundation for Children Tax ID# 95-6097416

Please Charge My: (Enter one: Visa, MasterCard MC, American Express AE)

Card # Exp.

Name on Card

Billing Address

City State Zip

Signature

Completed registration packets may be delivered to the 949 Roller Hockey Ctr., or Faxed to the 949 at: (949)559-9948, or emailed to [email protected] For more information, please refer to our web sitewww.GIVEBLOODPLAYHOCKEY.org or consult with your GBPH volunteer.

ONLINE REGISTRATION AND PAYMENT SITE: www.tinyurl.com/GBPH-REG-n-PAY


Giving the Gift of Life
http://www.tinyurl.com/GBPH-REG-n-PAYhttp://www.tinyurl.com/GBPH-REG-n-PAYmailto:[email protected]://www.tinyurl.com/GBPH-REG-n-PAYhttp://www.tinyurl.com/GBPH-REG-n-PAYhttp://www.tinyurl.com/GBPH-REG-n-PAYmailto:[email protected]://www.tinyurl.com/GBPH-REG-n-PAY


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DONATE GIVE BACK WIN!

CAKE AND SKATE WALKThis year we will be having our first annual cake and skate walk.Your team is encouraged to donate a wrapped baked good for this event. In return youwill receive 5-$1 raffle tickets! All baked items should be wrapped in clear cellophane andbrought to the event. All wrapped items should consist of at least a half dozen if cookies,

muffins, cupcakes or brownies. A whole cake or pie is considered one donation. Pleaseemail Traci Strale if you plan on participating: [email protected] have any questions.Please deliver your baked items the day you arrive to the check-in table at 949.

BASKET DONATIONSThis year we would like to encourage each team to donate one wrapped basket or gift cardvalued at $50 or more to the raffle and silent auction. In return you will receive 5-$1 and5-$5 raffle tickets which gives you even more chances to win items valued up to $500!

I would be extremely helpful if you would include with your basket the following:Youre Team Name

Basket NameAttach a list of items contained on a 3x5 index card

Retail Value $$Please email Traci Strale:[email protected], if you plan on participating or have

any questions.

All local teams can deliver their baskets prior to our event, please contact Traci for delivery or pick up options949-910-9886. Or bring to the check-in table the day you arrive.
mailto:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]


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Team Name

Division

Player Name Jersey # Phone Number Email address

Goalies:

Coach or Captain Name

Assist. Coach or Captain Name

I hereby certify that each of the players listed above are of the proper age and skill level for the division we areregistering our team.

Coach or Captain Signature

Date


OFFICIAL ROSTER


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TOURNAMENT$500 Registration Fee. Discounts offered for Early Bird registration and registered Blood Donors. Minimum 3games guaranteed. Round Robin -- Top Teams make playoffs. Awards for 1st and 2nd Place.

DIVISIONSCLUB Division includes: Atom Club - 8 & Under; Mite Club - 10& Under; Squirt Club - 12 & Under; Pee WeeClub - 14 & Under; Bantam Club - 16 & Under; and Midget Club - 18 & Under. Advanced, intermediate, andbeginner levels. Teams and Players must play in their appropriate level. [Age Cut off 12/31/2011]SCHOLASTIC Division includes: Middle School (grades 6-8); High School: Varsity, JVA, JVB and JVC; andCollege: D1 and D2 levels.ADULT Division includes: Beginner; Intermediate; and Advanced for both Men and Women.CO-ED Division includes Women and Men combined. Rules of play require 2 women on the rink at all times;

Woman goaltender counts for one player; Goals scored by Women count as 2-Points, Men for 1-Point each.

SKILLS COMPETITION$10 Enrollment Fee Per Player. Awards for: Most Creative Shot; Fastest Skater Award; Sniper Award; BreakAway Contest; and Top Goaltender. (Competitions sponsored by Mission Hockey and may be subject tochange. For info or to register,www.tinyurl.com/GBPH-REG-n-PAYor for more information email us [email protected]

GAME FORMAT2 - 15 Minute Periods. 3 Minute Warm Up. 1 Minute Intermission. Stop Time final 2 minutes with 2 goals oless differential. Standings Tie Breaker: Head to Head, Wins, GA, GD, GF, then Coin Toss. Ties during roundrobin playoff: 5 minute OT then Shoot Out. Games may start up to 30 minutes early.

RULESAge cut off as of 31-December-2011. Girls may play down one year below. Playing Rules are guided byUSARS.

Roster GuidelinesPlayers and Teams must play in their respective Skill Level(s). Teams may be asked to remove players fromtheir team if it deemed an individual(s) are playing at the wrong level. High School and Jr. High teams mushave players only from the school they attend. School IDs will be checked at registration. Home SchooledStudents may play for the school located in their school district. All players must be on the roster to participatein the tournament. Roster must be complete and final prior to 1st game. Waivers must be complete prior to1st game.

MANDATORY Coach/Manager Check-In at least One (1) hour prior to 1st game. Waivers and Roster Formsare attached and/or are available online under the Programs Section at www.949rollerhockey.com

ZERO ToleranceAny conduct unbecoming of the game or any fighting from players or participants, will NOT be tolerated andwill result in automatic expulsion of tournament participation at the discretion of the tournament directors.

Registration FeeAll Registration Fees must be paid in full prior to October 14th, 2011


TOURNAMENT RULES
http://www.tinyurl.com/GBPH-REG-n-PAYhttp://www.tinyurl.com/GBPH-REG-n-PAYhttp://www.tinyurl.com/GBPH-REG-n-PAYmailto:[email protected]:[email protected]:[email protected]://www.tinyurl.com/GBPH-REG-n-PAY


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Share Your Hockey With A HeartSpirit with our community through your contributions and pay-itforwardto children and those in need who this event strives to benefit. This year we have raised the bar againIn our 5thyear, we hope to host 95 teams in the tournament. Weve announced new divisions and events. TheAnaheim Ducks will be promoting the events in radio and television interviews. Players will be there as wilWild Wing, and the Power Players. There will be lots of fun things going on, but most importantly we wilsurpass the 800 pint mark in our blood drive, and we hope to reach the $200,000 level in total donations toCHOC. It is an exciting time!

If you, your team, your Company or a company you know, would also like to make a donationto this event, please complete the form below. No Donation is Too Big or Too Small to Help!

Please check or enter as applicable to describe your donation:YES. I/we would like to contribute: With Cash, Check or Credit Card In the Amount of $

With Goods or Services Valued at $

Describe:

Your Name or Contact

Company Name

Address

City State Zip

Home Phone Cell Phone

EMAIL (required)

Please Charge My: (Enter one: Visa, MasterCard, American Express) Enclosed is my check

Card # Exp. Please make checkpayable to:

CHOC Foundationfor Children

Tax ID# 95-6097416

Name on Card

Billing Address

City State Zip

Signature

No Donation is Too Bigor Too Small to Help!

Corporate Sponsors:Dale Quayle (714) 330-1602Food VendorsPeggy Quayle (714) 307-1980Fundraising Chair:Traci Strale (949) 910-9886Non-Food Vendors/Exhibitors:Julie Ruff(714)-318-7788

Please email this form to:

[email protected]

To learn more aboutCompany Sponsorship and

Exhibitor or Vendoropportunities at this event,please contact one of our

organizers for more details


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To: The Hockey Community

From: Mary Quayle Founder of the Give Blood Play Hockey Charity Tournament.

Subject: The 2011 Tournament Our 5th Year!

Date: Friday, July 15, 2011

It has been five years since we started the Give Blood Play Hockey Charity In-Line Tournament. Since then we have

raised over $130,000 for Children's Hospital of Orange County (CHOC), we've collected nearly 600 pints of blood and

we have watched cancer patients' miraculous and sometimes heart wrenching journey as they battle this horrible

disease. My name is Mary Quayle and I'm the founder of Give Blood Play Hockey.

Our event started as a simple idea and has grown far larger than we ever could have imagined. In 2010 we had 82

teams battling in 18 different divisions. The over 2000 spectators not only watched some competitive hockey, but

were also entertained by skills competitions, wheel chair hockey, dozens of vendors, lots of food and plenty of fun

entertainment for the entire family. Give Blood Play Hockey has become one of the largest hockey tournaments on the

west coast with over 600 individual players participating in the three day weekend event last year.

This year we have raised the bar again. In our 5th year, we hope to host 95 teams in the tournament. We've added

new divisions and events. We are proud to announce the Anaheim Ducks will be promoting the events in radio and

television interviews. Players will be they're as well, Wild Wing and the Power Players. There will be lots of fun things

going on but most importantly we will surpass the 800 pint mark in our blood drive, and we hope to reach

the $200,000 level in total donations to CHOC. It is an exciting time!

With the help of the hockey community, committed volunteers, gracious donors and people like you, we have built the

premier hockey event of the year. Won't you please join us as we celebrate our fifth year! You can read all about the

tournament and our event atwww.givebloodplayhockey.organd Like us on Facebook! Want to get involved, make a

donation, be a volunteer and help this awesome event? Email us [email protected]

The countdown to October 21st - October 23rd 2011 tournament has begun. We cannot wait to drop the first puck at

the 5th Annual Give Blood Play Hockey event. My name is Mary Quayle andI Give Blood and I Play Hockey.

Our History


ABOUT US
http://givebloodplayhockey.org/redesign2/events.phphttp://givebloodplayhockey.org/redesign2/events.phphttp://givebloodplayhockey.org/redesign2/events.phpmailto:[email protected]:[email protected]:[email protected]:[email protected]://givebloodplayhockey.org/redesign2/events.php


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949 Roller Hockey/Irvine Roller Rink, LLC/ The Rinks/ Give Blood Play HockeyRELEASE, ACKNOWLEDGEMENT OF RISKS AND INDEMNITY AGREEMENT

This document affects your legal rights. You must read and understand it before signing it.

I, the below named person being 18 or older in age, or the legal guardian of the below named person who is under 18, in considerationof the services of The 949 Roller Hockey/Irvine Roller Rink, LLC/ The Rinks/ Give Blood Play Hockey, its officers, affiliates, directors,members, managers, agents, employees, coaches, representatives and assigns all such others being herein collectively referred to asReleasees, the rate charged for those services, and the right to engage in this activity as a participant and/or volunteer, herebyacknowledge, agree, promise and covenant with Releasees on behalf of myself, and my heirs, successors, assigns, personalrepresentatives and estate as follows:Acknowledgement of RisksI understand and acknowledge that the activity I am about to voluntarily engage in as a participant and/or volunteer bears certain knownrisks and unanticipated risks which could result in INJURY, DEATH, PHYSICAL OR MENTAL ILLNESS OR DISEASE, OR DAMAGE tomyself, to my property, to spectators or to third parties. I understand and acknowledge those risks may result in personal claims againstReleasees, or claims against me by spectators or other third parties. These risks include but are in no way limited to the following (1)the risks which are inherent in the activities of roller hockey, roller skating, and hockey tournaments, events and competitions; (2) theacts, omissions or negligence in any degree of Releasees, or their agents or employees; (3) latent or apparent defects or conditions inequipment, property or facility provided by Releasees or their agents or employees; (4) physical contact with other participants, playersor competitors, whether or not such contact is intentional or unintentional; (5) my own physical condition, or lack thereof, and my ownacts or omissions; (6) first aid, emergency treatment, or other services rendered or failed to be rendered by Releasees, or their agentsor employees; and (7) risks of contact by equipment, pucks or other components utilized by other participants, players or competitors. IUNDERSTAND AND ACKNOWLEDGE that the above list is not complete or exhaustive, and that other risks known or unknown,identified or unidentified, anticipated or unanticipated, may also result in injury, death, illness, disease or damage to myself, to myproperty, or to spectators or other third parties.Acceptance of Risk and Responsibility

I voluntarily agree, covenant and promise to accept and assume all responsibilities and risks of injury, death, illness, disease or damageto myself or to my property arising from participation this activity. I expressly agree, covenant and promise to accept and assume allresponsibility and risk for injury, death, illness, disease, or damage to spectators or other third parties and their property arising from myparticipation in this activity. My participation in this activity is purely voluntary. No one is forcing me to participate in spite of the risks.ReleaseI voluntarily release and forever discharge and covenant not to sue Releasees and their agents and employees and all other persons orentities affiliated therewith, from any and all liability, claims, demands, actions or not limited to any and all negligence, fault or strictliability of Releasees and their agents or employees and all other persons or entities, for any and all injury, death, illness, disease anddamage to myself or to my property.IndemnificationI further agree, promise and covenant to hold harmless and to indemnify Releasees and their agents and employees, and all otherpersons or entities related thereto, from all defense costs, including attorneys fees, and from any other costs incurred in connectionwith claims for bodily injury or property damage which I may negligently or intentionally cause to spectators or other third parties in thecourse of my participation in this activity.Release of Unknown Claims

The releases extended in this document are general releases. I am aware of the provisions of California Civil Code Section 15 42, whichreads as follows: A general release does not extend to claims which the creditor does not know or suspect to exist in his favor at thetime of executing the release, which if known by him must have materially affected his settlement with the debtor. I hereby expresslywaive all the benefits of Section 1542 and any other similar law of any jurisdiction.Covenant Not to SueI further agree, promise and covenant not to sue, assert or otherwise maintain or assert any claim against Releasees or their agents oremployees, and all other persons or entities, for any injury, death, illness or disease, or damage to myself or my property, arising fromor connected with my participation in this activity or from any claims asserted against me by spectators or other third parties. In signingthis document, I fully recognize that if anyone is hurt or dies or property is damaged while I am engaged in this activity, I will have noright to make a claim or file a lawsuit against Releasees or their officers, agents or employees, even if they or any of them negligentlycaused the death, bodily injury or property damage.Acknowledgement of Effect of This Release AgreementI understand and acknowledge that by initialing and/or signing this document I have given up certain legal rights and/or possible claimswhich I might otherwise assert or maintain against Releasees or their agents or employees, and any other persons or entities, includingbut not limited to rights arising from other claims for the acts or omissions, fault or negligence in any degree of Releasees and their

agents or employees, and all other persons or entities. I understand and acknowledge that by initialing and/or signing this document, Ihave assumed responsibility and legal liability for the claims or other legal demands, including defense costs, which may be asserted byspectators or other third parties against me as a result of my participation in this activity.

___________Initials

3150 Barranca Parkway Irvine, CA 92606www.949rollerhockey.com
http://www.949rollerhockey.com/http://www.949rollerhockey.com/http://www.949rollerhockey.com/


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Participant Insurance Benefits and Representation of Physical ConditionI understand and acknowledge that no major medical insurance benefits will be provided to me during this activity other than by and through theinsurance provided by the insurer of The 949 Roller Hockey/Irvine Roller Rink, LLC/ The Rinks/ Give Blood Play Hockey. Purchase of thisinsurance is required prior to participation in any activity associated with the facility operated by its Releasees, agents and employees. If, forany reason, I have not purchased the insurance, I certify that I have sufficient health, accident, and personal liability insurance to cover anybodily injury, property damage, or disablement I may incur while participating in this activity, and to cover bodily injury or property damagedcaused to a third party as a result of my participation in this activity. I certify that I am capable of personally paying for any and all expenses,damages, or liabilities what are not covered by insurance. I further acknowledge that I am in good physical and mental health, and not sufferingfrom any condition, disease or disablement, which would or could potentially affect participation in the activity, or otherwise cause harm or injury

to myself or any other person.The 949 Roller Hockey/Irvine Roller Rink, LLC/ The Rinks/ Give Blood Play Hockey Rules & GuidelinesZERO TOLERANCE POLICYI below signed (named participant) agree to comply with The 949 Roller Hockey/Irvine Roller Rink, LLC/ The Rinks/ Give Blood Play Hockeyspolicy of zero tolerance. This applies to all programs and sports concerning physical altercation (fighting); use of obscene, profane or abusivelanguage; challenging or disputing officials or disrupting any event. I understand these violations can result in being ejected from a game,suspended or removed from a program permanently. For further details contact front desk or management about rules for hockey and all othersports leagues.Equipment Requirements Alternate SportsI below signed (named participant) will comply with all 949 Roller Hockey/Irvine Roller Rink, LLC/ The Rinks/ Give Blood Play Hockeyequipment requirements involving any hockey activity and wear the following: an H.E.C.C. approved helmet with strap and full face shieldfor youth and goaltenders with a colored mouth guard connected to the shield, (B) elbow pads, (C) jersey, (D) gloves, (E) protective cup, (F)pants, (G) knee/shin pads, (H) hockey inline skates with no exposed bolts or brake pads must be taped (I) stick butt end taped (no blacktape), maximum3/4 curved blade and (J) shoulder pads highly recommended for youth. Adults require same equipment except no face shieldrequired. We recommend a 76A wheel for sports court floors. If a player is injured and is not wearing all the required equipment, the insuranceMAY not be in effect to cover the claim.

Equipment Requirements Alternate SportsI below signed (named participant) will comply with all 949 Roller Hockey/Irvine Roller Rink, LLC/ The Rinks/ Give Blood Play Hockeyequipment requirements involving any sports activity and wear the appropriate equipment for all the sports in which I am participating. Forfurther details, consult the league rules and equipment requirements for the respective sports activity or contact the facility management.General Stipulations(A) All participants must pay in full, prior to start date. (B) The 949 Roller Hockey/Irvine Roller Rink, LLC/ The Rinks/ Give Blood Play Hockey,its subsidiaries and affiliates reserve the right to change the start date and times. (C) Cancellation period applies only prior to start date of theprogram and no refunds will be considered after that period. No refunds will be allowed for registration and membership fees. (D) In the eventthat a participant cannot make the regularly scheduled session or alternate session, a makeup session may not be taken. There will be nocredit or refund for absences. The 949 Roller Hockey/Irvine Roller Rink, LLC/ The Rinks/ Give Blood Play Hockey its subsidiaries and affiliatesreserve the right to cancel this contract for any default by the participant within the terms of this contract. The 949 Roller Hockey/Irvine RollerRink, LLC/ The Rinks/ Give Blood Play Hockey cannot be responsible for any lost or stolen property. A Non Sufficient Funds check requiresimmediate reimbursement or cancellation of game schedule will take place.General Medical TreatmentI hereby permit The 949 Roller Hockey/Irvine Roller Rink, LLC/ The Rinks/ Give Blood Play Hockey and any subsidiary or affili ate whichoperates the Center in which the undersigned engages in recreational activity and their respective employees, agents, and representatives toauthorize any medical treatment for me in the event of an emergency.Authorization to Treat a MinorI(we), the below signed parent or legal guardians of the below named participant who is a minor, do hereby authorize and consent to any x-rayexamination, anesthetic, medical or surgical diagnosis or treatment and hospital care which is deemed advisable and rendered under thegeneral or special supervision of any member of the medical staff or emergency staff licensed under the provisions of the Medical Practice Actand on the staff of any accredited general hospital holding a current license to operate as a hospital in the State of California. It is understoodthat this authorization, given in advance of any specific diagnosis, treatment or hospital care being required, is given to provide authority andpower to render care which the aforementioned physician in the exercise if his or her own best judgment may deem advisable. It is understoodthat an effort shall be made to contact the below signed prior to rendering treatment to the patient, but that none of the above treatment will bewithheld if the below signed cannot be reached.Photo & Video ReleaseI the below (named participant) grant full permission to The 949 Roller Hockey/Irvine Roller Rink, LLC/ The Rinks/ Give Blood Play Hockey, itssubsidiaries and affiliates to use any photographs, video tapes, pictures or recording of any practice or league game activity for promotional orinstructional or general viewing purposes.Entire Agreement

I understand that this entire agreement between the below signed and Releasees and their agents and employees, and that it cannot bemodified or changed in any way by the representations or statements of Releasees or any employee or agent of Releasees, or by the belowsigned and is valid and effective for each and every activity and session in which the undersigned participates at any facility operated by The949 Roller Hockey/Irvine Roller Rink, LLC/ The Rinks/Give Blood Play Hockey, it subsidiaries and/or affiliates.

Name of Participant (Please Print) ____________________________________________Date of Birth _________________________

Signature of Participant or Guardian (if under 18yrs) ______________________________________________Date: _______________

Home Address____________________________________________City______________________Zip Code___________________

Cell Phone #__________________________Alt. Phone#_________________________Parents_______________________________

School Attending____________________________________Email Address______________________________________________

give blood play hockey registration forms 2011

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