PRINT, COMPLETE, SIGN, MAIL OR FAX TO ROBERT MUDLOFF
By Mail: Mr. Bob Mudloff, 17368 Buckingham Avenue, Beverly Hills, MI 48025
By E- Mail: Scan and Send To; muddeee@sbcglobal.net OR FAX: 248 642 5245
MICHIGAN STING HOCKEY CLUB – REGISTRATION WAIVER
2010 Thru 2013
Participant Registration Statement of Responsibilities & Agreement
Medical Statement / Waiver, Hold Harmless & Indemnity Agreement
Registration / Revised – Feb, 2009 - Page 1 of 2
Referred by: __________________________ (For New Players Only)
Date Application Is Being Completed / Updated / Submitted; ______ / _______ / ___________
Name_____________________________________________________________________
First, Middle, Last
Address_________________________________ City___________________ State______
Zip Code__________ E-Mail___________________________________________________
Phones: (Home) ( ______)___________________ (Work)(______)____________________
Phones: (Cell) (______)___________________ (Fax) (______)____________________
Date of Birth ______-______-_______ Age_____
Position: LW – C – RW – LD – RD – G (Circle first choice, box second choice)
Participant Statement of Responsibilities & Agreement
Ice hockey is a physically active sport and participation may result in physical injuries. Injuries may
result in minimal or severe damage to ones body: (i.e. bruises, cuts, broken bones, injuries to eyes
and teeth among other things). Injuries may include catastrophic consequences, including but not
limited to permanent paralysis or even death.
I fully understand the personal and family risks associated with participation in ice hockey. I also
understand it to be my responsibility to take all safety steps by utilizing the appropriate equipment
necessary to keep myself protected. I will follow the rules of hockey and play within the spirit of the
rules. I will only use my body and equipment for purposes provided by the rules. I will not check
any other player and I will avoid aggressive acts and keep my emotions under control at all times.
I agree to have an annual physical to validate my health and fitness.
I understand and agree that I participate in this sport and with this group at my own risk.
I further understand ice hockey players are legally liable for injuries to others due to “reckless disregard” for the safety to others.
I will share this agreement and information with my spouse and family members.
MICHIGAN STING HOCKEY CLUB – REGISTRATION WAIVER
Participant Registration Statement of Responsibilities & Agreement
Medical Statement / Waiver, Hold Harmless & Indemnity Agreement
Registration / Revised – Feb, 2009 - Page 2 of 2
Medical Statement
Skating at my own risk, I understand the dangers of the sport and the need to have the appropriate
medical insurance coverage. I also acknowledge there are no forms of insurance coverage provided
to me by anyone or any organization through my participation with this organization.
I accept full responsibility to provide all insurance coverage desired and I will provide primary and
catastrophic medical insurance in the event of injury. I further agree to notify the organization if the
status of coverage changes. I agree not to participate without having insurance coverage in place.
My insurance information is provided below:
Name of Insurance Provider_________________________________________
Policy Number____________________________________________________
Other____________________________________________________________
Waiver, Hold Harmless and Indemnification Agreement
I am aware that efforts are being made on my behalf by this organization to provide a positive venue
for ice hockey. It is with this understanding and full knowledge of the risks of playing ice hockey, to me
and the potential affects to my family, in the case of injury, that I unconditionally waive my/our rights of
recovery from this organization, its affiliates, organizers, sponsors, successors, assigns, heirs,
directors, officers, administrators coaches and managers.
In consideration for the opportunity to participate, I hereby understand and agree, it is a condition of participation, that I unconditionally release, forever discharge, hold harmless and indemnify this
organization, its affiliates, organizers, sponsors, successors, assigns, heirs, directors, officers,
administrators, coaches and managers from any and all liability and or claims foreseen or unforeseen surrounding my participation with this organization as an ice hockey player or otherwise. I agree this
Waiver, Hold Harmless and Indemnification will extend to the Michigan Sting Hockey Club and its
organizers as a co-organizer of this league.
This Agreement, Waiver, Hold Harmless and Indemnification Agreement apply to any and all activities,
events or outings wherever they are held. The conditions within the above, apply to affiliates who are
either directly or indirectly involved in supporting MSHC activities, events or outings.
I fully accept and agree to all conditions set forth.
Print Name _______________________________________________
Signature ________________________________________________
Date ________/________/____________________