FIELD HOCKEYSkylands Field Hockey Association

coming Fall Season:(Grades 2-S)(Grades 6-8)

Offering teamsJuniorSenior

for the upDivisionDivision

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. Welcoming players from the Warren County area!Home games played on the Belvidere High School athletic fields.Registration fee of $45 made payable to:

Skylands Field Hockey Association. Fill out form below and mail with check to:

Caralee Gately, Registration Coordinator7LL Franklin Street, Belvidere, NJ 07823

o For more information or have questions, please e-mail us atskyl a ndsfield hockey@ g ma i I . com

o Check out our webpage at www.skylandsfieldhockey.org

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:j Player's Name:

Field Hockey Registration Form

i Players Age: Years of playing experience:

i Rlayert Grade in September 2011:

i Parent's Name(s):I

! Mailing Address:t

! Home Phone:I

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The Skylands Field Hockey Association also offers an Adult Woment Pick Up League playingSpring and Summer sessions. Contact us at skylandsfieldhockey@gmail,com for more information.

The Skylands Field Hockey Association is a registered NJ nonproftt corporation.

Skylands Field Hockey Association

Player Name: Date of Birth:

Team (circle one): Junior Division (Grades 2-5) Senior Division (Grades 6-8)

Parent or Guardian Authorization:

In case of emergency, if family physician cannot be reached, I hereby authorize my childto be treated by Certified Medical Personnel (i.e. EMT, First Responder, E.R. physician,etc.).

Family Physician: Phone:Address:Hospital Preference:

In Case of Emergencv Contact:

Name Phone home/cell Relationship to player

Name Phone home/cell Relationship to player

Name Phone home/cell

Please list any allersies/medical problems:

Relationship to player

Medical Diagnosis Medication Dosage Frequency of Dosage

The purpose of the above listed information is to ensure that medical personnel have details of any medical problems, which mayimpact emergency treatment.

Please note any medical issues that your child's coach may need to know forpractices and games:

Pare4t or Guardian Authorization. Disclaimer. and Waiver of Liability

As the parent/legal guardian of _, I give my approval for his/her participation in any and allactivities during the current season for the team listed above. I assume all risks and hazards incidental tosuch participation including transportation to and from all activities. I do hereby waive, release, absolve,indemnify and agree to hold harmless the participants in the Skylands Field Hockey Association for anyclaims arising out of any injury to my child, expect to the extent and in the amount covered by the accident-Iiability insurance carried by the Association. I acknowledge and recognize that participation and behavioris subject to the by-laws established by the association.

I also give my permission for the Skylands Field Hockey Association to take and use any photograph orvideo/audio recording in which my child appears for promotional purposes on the association website.