Name:					Date of Birth:
Address:				City:			State:
Zip Code:			Email:			Phone:
Emergency Contact:					Emergency Phone:
Youth In-Line Leagues				Adult In-Line Leagues			In-Line Session
¨ 8 & Under				¨ Puck A			¨ Spring
¨ 10 & Under				¨ Puck B			¨ Summer
¨ 12 & Under				¨ Puck C			¨ Fall
¨ 14 & Under				¨ Puck D			¨ Winter
¨ High School (17U)				¨ Puck E
				¨ Puck F
				¨ 30+
Team Name:				¨ Ball
				¨ Dek
Early Reg:	Y  /   N
				Tournaments
Hockey					Dodgeball
¨ Turkey Shoot Out					¨ Dodge-It Fall Tourney
¨ Santa's Classic					¨ Winter Slam Tourney
¨ Constitution Cup
¨ Spring Warm-Up Challenge					Ultimate Frisbee
¨ Iron Man					¨ Winter Adult Classic Tourney
¨ Nutmeg State Games					¨ Winter Funk Tourney
¨ Champions Cup
				¨ Waiver Only
Participant Release of Liability (Please read before signing below)
The risk of injury from the activities involved in this program is potentially significant, including the potential for permanent paralysis and death, and while
particular rules, equipment, and personal discipline may reduce the risk, I knowingly and freely assume all such risks, both known and unknown, even if arising
from the negligence of the releasees or others, and assume full responsibility for my participation; I willingly agree to 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, I, for myself and on behalf of my heirs, assigns, personal representatives
and next of kin, hereby release, indemnify, and hold harmless ZRink, their officers, officials, agents and/or employees, other participants, sponsoring agencies,
sponsors, advertisers, and, if applicable, owners and lessors of premises used to conduct the event, with respect to any and all injury, disability, death, or loss
or damage to person or property, to the fullest extent permitted by law.  If under 18 at time of registration, I, as parent/guardian with legal
responsibility for this participant, do consent and agree to his/her release as provided above.
Participant/Guardian Signature________________________Particpant/Guardian Name_________________________
Medical Condition(s)________________________Date__________
Office Use Only:  Total Amount Due__________Total Payment__________Rec'd by__________
Payment Method_________Check #__________Payment Date__________