US Field Hockey Association
Membership Application Please Return with check or
money order (no cash) payable to
US Field Hockey, One Olympic Plaza, Colorado Springs, CO 80909
New Member Renewal
Social Security Male Female
Last Name
First Name MI
Date of Birth U.S. Citizen Yes No
Address
City State Zip
Phone Work
Fax e-mail WAIVER & RELEASE MUST BE
SIGNED OR APPLICATION WILL BE RETURNED TO YOU CODE OF CONDUCT MUST ALSO BE SIGNED WITH
THIS APPLICATION
Waiver
and release of Liability Must
be completed by ALL members In
consideration of being allowed to participate in any way in the United States Field Hockey
Association programs, related
events and activities, the undersigned acknowledges, appreciates and willingly agrees
that:
1.
I will comply with the stated and customary terms and conditions for participation. If,
however, I observe any unusual
significant hazard during my presence or participation, I will remove myself from
participation and bring such
to the attention of the nearest official immediately; and
MEMBERSHIP OPTIONS
ATHLETE
Youth (U14)
$10
U21 (age 14-21)
$25
Adult (21 & over)
$35
PROFESSIONAL
Coach 1 YEAR
$40
Umpire 1 Year
$40
OTHER
Patron
$30
Family
(2 adults, 2 U21 or youth)
Please include separate application for each member
$70
Life Member
$500
Applicants
must be 35 years old or older for life memberships
Donation to USFHA
Total
2. I acknowledge and fully understand that each participant will be engaging in activities
that involve risk of
serious injury, including permanent disability and death, and sever social and economic
losses which may result
not only from their own actions, inactions or negligence but the action, inaction or
negligence of others, the
rules of play, or the condition of the premises or of any equipment used. Further, I
accept personal responsibility for
the damages following such injury, permanent disability or death; and,
3.
I knowingly and freely assume all such risk, both known and unknown, even those arising
from the
negligent acts or omissions of others, and assume full responsibility for my
participation; and
4.
I, for myself and on behalf of my heirs, assigns, personal representatives and next of
kin, hereby release, hold
harmless the United States Field Hockey Association, its officers, officials, affiliated
clubs, their respective administra- tors,
directors, agents, coaches, and other employees of the organization, other participants,
sponsoring agencies advertisers,
and , if applicable owners and lessors of premises used to conduct the event, all of which
are herein- after
referred to as "releasees," with respect to all and any injury, disability,
death or loss or damage to person or
property, whether arising from the negligence of the releasees or otherwise, to the
fullestextent
permitted by law.
I have read this release of liability and assumption of risk agreement, fully understand
its terms, understand that I have
given up substantial rights by signing it and sign it freely and voluntarily without any
inducement.
_______________________________________________________________ Participant's
signature (even if under 18)
Date
For
parents/guardians of participants under 18 at time of registration. This
is to certify that I, as parents/guardian with legal responsibility for this participant,
do consent and agree to his/ her
release, as provided above, of all the Releasees, and, for myself, my heirs, assigns, and
next of kin, I release and
agree to indemnify and hold harmless the releaseesfrom
any and all liabilities incident to my minor child's involvement
or participation in these programs as provided above, even if arising from their
negligence, to the fullest extent permitted by law.
_______________________________________________________________ Parent/Guardian
Signature
Date
US Field Hockey Association
Membership Application