SPORTSZONE INDIVIDUAL REGISTRATION/WAIVER FORM

SPORT/ACTIVITY _________________________________________________   DATE ______________

DIVISION/LEAGUE __________________________________  SESSION _________________________

PLEASE CHECK ONE: FEMALE ________  MALE _________  D.O.B. ___________  GRADE ______

PLEASE PRINT:

Name  _____________________________________________________________________________

Address  _____________________________________________________________________________

City, State, Zip  _______________________________________________________________________

E-mail Address  _______________________________________________________________________

     I/we realize that for my/our child, or for myself, that participation in the active, physical sport that I/he/she am/is undertaking at the SportsZone, can result in injuries during participation. I/we have sought the opinion of my/our child's pediatrician/physician and he/she concurs that the participant is fully capable of safely participating in this activity. I/we understand that it is my/our responsibility in caring for the participant(s) listed above and I/we are confident that he/she is fully capable of engaging in this activity. I/we further agree to hold harmless the SportsZone Corporation from any and all legal and financial liability connected with providing facilities for the purpose of participating in athletic and related activities. I/we, our heirs, executors, administrators and assigns waive, release and forever discharge the SportsZone Corporation, its directors, employees, any and all related parties from all rights and claims for damages, injury or loss of person or property which may be sustained or occur before/during/or after participation on the premises of the SportsZone whether or not due to negligence. I/we take full responsibility for accidents or injury to, or caused by, my child or myself during, participation, or otherwise, while on the SportsZone premises. I/we hereby certify that I/we have medical insurance to cover injury to my child or myself. In the event of injury or illness, the SportsZone has my permission to seek any emergency medical treatment deemed necessary for me/or my child.

_____________________________________________________________________________________
Participant's Signature

_____________________________________________________________________________________
Signature of Parent/Guardian (If Participant is under 18 years old)

Phone: H__________________________________   W _______________________________________

Cell  ___________________________________ 

E-mail_______________________________________

Insurance Co. _________________________________________________________________________

Name of Policy Holder  _________________________________________________________________

Policy No.  ___________________________________________________________________________

PLEASE MAKE CHECK PAYABLE TO: SPORTSZONE CORPORATION
AND SUBMIT ALONG WITH THIS FORM TO: 7 'A' STREET, DERRY, NH 03038

*THERE WILL BE A $25.00 FEE FOR RETURNED AND/OR CANCELED CHECKS

FOR OFFICE USE ONLY:

Date _______________ Amount________________ Check #_______________ or Cash _____

By_________________