REGISTRATIONFORM FUTSAL2014/2015 Please fill out the required information and email to [email protected] or bring to the scheduled Futsal drop‐in days (October 26th, 2014 and November 2nd, 2014) at the Northern Lights College gym. Payment and the signed ASSUMPTION OF RISKS (if not already submitted) will be accepted on the first league game November 16th, 2014. Both the signed ASSUMPTIONS OF RISK and payment must be submitted to the league prior to participation in the league. PLAYERINFORMATION Name Email Address cell home Phone Number work other Date of Birth Are you a Goalie? YES NO Are you available to Referee? YES NO TEAMINFORMATION Do you have a team you will be playing on? (If NO the league will place you on a team) YES NO Team Name Team Captain ASSUMPTIONOFRISKS Please read the attached ASSUMPTIONS OF RISKS. The DCASL carries both Accident and General Liability Insurance through Sports‐Can Insurance Consultants Ltd. Registrationfeeof$60andsignedASSUMPTIONOFRISKSdueatfirstdayof th leagueplayNovember16 ,2014attheregistrationdesk.Cashonly. 1 | 2 REGISTRATIONFORM FUTSAL2014/2015 ASSUMPTIONOFRISKS ** Please sign and bring to first game ** ** For participants under the age of 19 please have a parent or guardian sign ** Initial here I am aware that participating in the activities and sports, without limitation, offered by or associated with Dawson Creek Adult Soccer League (DCASL), exposes me to many inherent risks, dangers and hazards. By engaging in any activities offered by or associated with DCASL, I freely accept and fully assume all inherent risks, dangers and hazards and the possibility of personal injury, death, property damage or loss resulting there from. RELEASE OF LIABILITY WAIVER OF CLAIMS & INDEMNITY AGREEMENT In consideration of DCASL permitting me to participate in its activities and sports, permitting me to the use of its equipment and permitting me the use of any facilities, I hereby agree as follows: 1. TO WAIVE ANY AND ALL CLAIMS that I have or may in the future have against DCASL, and its directors, officers, employees, agents, representatives, assigns and successors. 2. TO RELEASE DCASL, and its directors, officers, employees, agents, representatives, assigns and successors from any and all liability for any loss, damage, injury or expense that I may suffer or that my next of kin may suffer, as a result of my participation in activities and sports offered by DCASL, due to any cause whatsoever. 3. TO HOLD HARMLESS AND INDEMNIFY DCASL, and its directors, officers, employees, agents, representatives, assigns and successors from any and all liability for any property damage or personal injury to any third party, resulting from my activities and my participation in the activities offered by or associated with DCASL. 4. I agree to the use of my picture or image, if taken in the performance of DCASL activities for use by the DCASL in publications, websites and advertisements. 5. That this Agreement shall be effective and binding upon any heirs, next of kin, executors, administrators and assigns in the event of my death. 6. Participants acknowledge that the Dawson Creek Adult Soccer League is NOT registered or affiliated with provincial soccer associations including British Columbia (BCSA) or Alberta (ASA). 7. I have read and understood this Agreement prior to signing it. I am aware that by signing below, I am waiving certain legal rights which I or any heirs, next of kin, executors, administrators and assigns may have against DCASL and its directors, officers, employees, agents, representatives, assigns and successors. SIGNATURE PRINT NAME DATE Registrationfeeof$60andsignedASSUMPTIONOFRISKSdueatfirstdayof th leagueplayNovember16 ,2014attheregistrationdesk.Cashonly. 2 | 2