gbph2012 registration packet

7/31/2019 GBPH2012 Registration Packet

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Dear Hockey Coaches, Managers, Captains, Players and Friends:

You, your team and your entire family are invited to join us for the 6th AnnualGive Blood Play Hockey InlineHockey Charity Tournamenta serious hockey tournament with a serious purpose! While teams will becompeting on the rinks for their spot on the perpetual trophythe Blood Cup, theres plenty of off-rink fun forthe whole family. Proceeds from the weekend long event will benefit CHOC Childrens Hospital; plus well begiving the gift of life through your valuable Blood Donations.

This years tournament will be held November 2nd-4th at The Rinks Irvine Inline and will host division teamsfrom Tyke to Adult, Scholastic, Mens and Womens, and beginner through professional.

This year promises to be another great tournament for all teams. Inquiries have been steadily pouring in fromacross the Southland. And Good News! This years fees are the same as last years! Your tournament entryfee is tax deductible, and if you register at least two adults to give blood you can apply a $25 discount to yourregistration fee. We expect this to be a sold-out event, so please take advantage of early registration and sign-up today! SPACE IS LIMITED TO 95 TEAMS, SO PLEASE RESPOND IMMEDIATELY BY E-MAIL TOGUARANTEE YOUR SPOT.

ONLINE REGISTRATION AND PAYMENT BEGINNING JULY 1st AThttp://www.tinyurl.com/GBPH2012

In addition to some competitive hockey, the tournament features fun events for the whole family. You wontwant to miss our skills competition, rink-side vendors, games and displays all in a carnival-like settingAttendees can also buy raffle tickets for chances to win donated high-ticket items, hockey equipment; andmuch, much more! New events and sponsors are being added regularly if you or your company would like toparticipate, please contact us.

GIVE BLOOD. GIVE LIFE. Its Hockey With A Heart!The Bloodmobiles also will be at the event so attendees cangive a very special donation of another kindtheir blood!Plan to take some of your valuable time while attending andBe A Hero and Give Blood. It doesnt hurt. Honest!

Please review the information included with this packet; it describes the tournament rules, gives details aboutthe format and different levels of play, registration information, and the required paperwork to register your

team. It also describes the incredible work being done by our volunteers to help our beneficiary organizationssuch as CHOC Childrens Hospital and the children that this event will support.

If you have registration questions, please call us at (714) 330-1602, or send an e-mail [email protected]. Most importantly, register soon to reserve your space in the most important hockeytournament of the year!

Thank You!The GBPH Organizing Committee www.GIVEBLOODPLAYHOCKEY.org

November 2-4, 2012The Rinks - Irvine, CA

PLEASE JOIN US!


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Give Blood Play Hockey

Inline Hockey Charity TournamentSerious Hockey for a Serious Cause

November 2-4, 2012

THE RINKS IRVINE INLINE, Irvine, CaliforniaThe 6th annual Give Blood Play Hockey Inline Hockey Charity Tournament (GBPH) is an Irvinebased, family oriented event that will once again draw thousands of hockey players and fans to aweekend long, carnival like atmosphere designed to showcase hockey talent while giving back to thecommunity. Founded in 2007 by then Mater Dei High School senior and hockey player Mary Quaylethis tournament began as a service project motivated by her desire to pay back to the community theblood donated to her late grandfather and pay it forward to children and those in need in ourcommunity.To date, the GBPH tournament has collected over 800 pints of life saving blood and donated over$175,000 to CHOC Childrens Hospital with a pledge of $150,000 to build an Oncology Patient Room

and Oncology Medication Station in the new wing of the hospital scheduled to open in 2013. Wevehosted hundreds of hockey teams, seen some crazy skills in the Skills Competition, and raffled offsome amazing prizes including Ducks and Kings tickets, hockey equipment, weekend getawayshelicopter rides and more. We have also had the pleasure of seeing CHOCO Bear, Ryan GetzlafBobby Ryan, and Kyle Chipchura, Wild Wing, the Power Players and other distinguished guestsduring our first 5 tournaments.This year, we are raising the bar again in our blood donation and fundraising efforts. We willcontinue to celebrate the ongoing recovery of one of our own hockey players, Casey Strale, who wasdiagnosed with cancer during our 3rd tournament and is back playing at the top of his game, andfind more ways to pay it forward for all the children served at CHOC Childrens Hospital.To learn more about this event or register a team, please contact us by email at:

[email protected], visit our web site at www.GIVEBLOODPLAYHOCKEY.orgor join us on Facebook at: http://www.facebook.com/pages/Give-Blood-Play-Hockey/114966515217989

For more information about how you can participate or help in our community cause, please contact us:

THE RINKS IRVINE INLINE3150 Barranca Parkway

Irvine, CA 92606-5202(949) 559-9949http://irvineinline.com

Eddie [email protected]

Event ContactsCorporate Sponsors/Media &Marketing:Dale Quayle (714) 330-1602

[email protected] Vendors:Peggy Quayle (714) 307-1980Fundraising/Raffle/SilentAuction:Traci Strale (949) 910-9886Team Registrations/Non-foodVendors/Exhibitors:Julie Ruff (714) 318-7788Blood Donations:Katherine Halbeck (949) 433-4911Volunteers:Chris Strale (949) 910-4129

For more information, send email [email protected] or call(714) 330-1602

Visit our web site:GIVEBLOODPLAYHOCKEY.org


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Heres the 411 on Registering Your Team

1. All Team Registrants Must Complete and Submit: TEAM REGISTRATION INFORMATION, page 1 and 2.

Complete these two forms and payment for registering your teamSubmit completed forms to the contacts listed below before Friday, October 26, 2012

OFFICIAL ROSTERComplete this form and submit when checking in your team at the event

2. All Players Must Complete and Submit: RINKS WAIVER FORM (attached with email or by request from The Rinks or on site)

Complete this form(s) and submit when checking in your team at the event

*PLAY *GIVE *DONATE *SAVE!Teams registered by October 5 th pay *$450, after that, the fee increases to $500. All registrations must becompleted and paid in full by October 26th. Sign up two blood donors and save $25 on your fees. Pay feeon line at http://www.tinyurl.com/GBPH2012

ONLINE REGISTRATION AND PAYMENT BEGINNING JULY 1st AThttp://www.tinyurl.com/GBPH2012

Or Submit Your Completed Registration Packet To:

The Rinks Irvine InlineAttn: Eddie Limbaga3150 Barranca ParkwayIrvine, CA 92606

ANY TEAM THAT BRINGS IN A $1000 SPONSOR OR ABOVE WILL GET A FREE TEAM

REGISTRATION.

If you, your team, or your Company would also like to make a donation to this event, pleasealso include the Sponsor Form included with this packet - No Donation is Too Big or TooSmall to Help!

November 2-4, 2012The Rinks Irvine Inline - Irvine, CA

TEAM REGISTRATION


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ONLINE REGISTRATION AND PAYMENT NOW AVAILABLEhttp://www.tinyurl.com/GBPH2012

TEAM REGISTRATION INFORMATION Page

1 of 2

Team Name

Coach/Manager Name

Coach/Manager Address

City State Zip

Home Phone Cell Phone

EMAIL (required)

Please complete the following registration information by checking the blank next to the division and level of

play for your team (type in X). Please complete one form for each team you wish to register. Age cut off fothe club division is based on the players age as of December 31st, 2012. Please see the roster guidelineswith the enclosed tournament rules and regulations.

Club Division (Need to convert Age to Club Division? See our Tournament Rules to learn more.)

Age Level 8U 10U 12U 14U 16U 18U Adult

Skill Level Beginner Intermediate Advanced

Team Gender Male Female Co-Ed

Scholastic Division

Jr. High Varsity JVA

High School Varsity JVA JVB JVC

College Div. 1 Div.2

What Division did this Team play in the 2011-2012 Season (or Last)?

What is this Teams Home Rink? (enter name of rink)

Any Comments about this Team?

MORE REGISTRATION DETAILS ON NEXT PAGE

NOVEMBER 2-4, 2012 - Irvine, CA


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TEAM REGISTRATION INFORMATION Page2 of 2

Team Name

Age Level / Division

PLAY. GIVE. DONATE. SAVE!Team registration fees are tax deductible. If you register at least two adults to give blood you can apply a $25discount to your registration fee. Pay early and save $50! Register online or use this form.

ONLINE REGISTRATION AND PAYMENT SITE: http://www.tinyurl.com/GBPH2012

Select your tournament entry fee:$450 PER TEAM Early registration by October 5, 2012

$500 PER TEAM Registration after October 5, 2012

$25 PER TEAM Discount for Two Blood Donations

$1000SPONSORSHIP

Team Registration Fee is Included

$ Your Team Fee $

DONORS:

Blood Donor #1 Name Age Phone

Blood Donor #2 Name Age Phone

Yes we would like to donate a gift basket and get free raffle tickets (see next page)

Yes we would like to donate baked goods and get free raffle tickets (see next page)

All fees are to be paid by credit card, cash, check, or money order and are due by October 26, 2012. Please

make checks payable to: CHOC Foundation Tax ID# 95-6097416

Please Charge My: (Enter one: Visa, MasterCard MC, American Express AE)

Card # Exp.

Name on Card

Billing Address

City State Zip

Signature

Completed registration packets may be delivered to The Rinks Irvine Inline, or Faxed to The Rinks at: (949)559-9948, or emailed to [email protected] For more information, please refer to our websitewww.GIVEBLOODPLAYHOCKEY.org or consult with your GBPH volunteer.

ONLINE REGISTRATION AND PAYMENT SITE: http://www.tinyurl.com/GBPH2012

NOVEMBER 2-4, 2012The Rinks Irvine Inline - Irvine, CA

Giving the Gift of Life


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Back this year by popular demand our cake and skate walk, offering tasty treats and fun

for the whole family.

Your team is encouraged to donate a wrapped baked good for this event. In return you

will receive 5-$1 raffle tickets! All baked items should be wrapped in clear cellophane and

brought to the event. All wrapped items should consist of at least half a dozen cookies,muffins, cupcakes or brownies. A whole cake or pie is considered one donation. Please

email or call Pam Goddard if you plan on participating: tel: [email protected] or have any questions.Please deliver your baked items the day you arrive to the check-in table at The Rinks.

This year we would like to encourage each team to donate one wrapped basket or gift card

valued at $50 or more to the raffle and silent auction. In return you will receive 5-$1 and

5-$5 raffle tickets which gives you even more chances to win items valued up to $500!

It would be extremely helpful if you would include with your basket the following:Your Team Name

Basket NameAttach a list of items contained on a 3x5 index card

Retail Value $$Please email or call Traci Strale, 949-910-9886, [email protected], if you plan on

participating or have any questions.


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Team Name

Division

Player Name Jersey # Phone Number Email address

Goalies:

Coach or Captain Name

Assist. Coach or Captain Name

I hereby certify that each of the players listed above are of the proper age and skill level for the division we areregistering our team.

Coach or Captain Signature

Date

November 2-4, 2012The Rinks Inline Irvine - Irvine, CA

OFFICIAL ROSTER


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TOURNAMENT$500 Registration Fee. Discounts offered for Early Bird registration and registered Blood Donors. Minimum 3games guaranteed. Round Robin -- Top Teams make playoffs.

$1000 SPONSORSHIPS AND ABOVE INCLUDE A TEAM REGISTRATION FEE.

DIVISIONSCLUB Division includes: Atom Club - 8 & Under; Mite Club - 10& Under; Squirt Club - 12 & Under; Pee WeeClub - 14 & Under; Bantam Club - 16 & Under; and Midget Club - 18 & Under. Advanced, intermediate, andbeginner levels. Teams and Players must play in their appropriate level. [Age Cut off 12/31/2012]SCHOLASTIC Division includes: Middle School (grades 6-8); High School: Varsity, JVA, JVB and JVC; and

College: D1 and D2 levels.ADULT Division includes: Beginner; Intermediate; and Advanced for both Men and Women.CO-ED Division includes Women and Men combined. Rules of play require 2 women on the rink at all times;Woman goaltender counts for one player; Goals scored by Women count as 2-Points, Men for 1-Point each.

SKILLS COMPETITION$10 Enrollment Fee Per Player. Awards for: Most Creative Shot; Fastest Skater Award; Sniper Award; BreakAway Contest; and Top Goaltender. (Competitions sponsored by Mission Hockey and may be subject tochange.

GAME FORMAT2 - 15 Minute Periods. 3 Minute Warm Up. 1 Minute Intermission. Stop Time final 2 minutes with 2 goals oless differential. Standings Tie Breaker: Head to Head, Wins, GA, GD, GF, then Coin Toss. Ties during round

robin playoff: 5 minute OT then Shoot Out. Games may start up to 30 minutes early.

RULESAge cut off 12/31/2012. Girls may play down one year below. Playing Rules are guided by USARS.

Roster GuidelinesPlayers and Teams must play in their respective Skill Level(s). Teams may be asked to remove players fromtheir team if it deemed an individual(s) are playing at the wrong level. High School and Jr. High teams mushave players only from the school they attend. School IDs will be checked at registration. Home SchooledStudents may play for the school located in their school district. All players must be on the roster to participatein the tournament. Roster must be complete and final prior to 1st game. Waivers must be complete prior to1st game.

MANDATORY Coach/Manager Check-In at least One (1) hour prior to 1st game. Waivers and Roster Formsare attached and/or are available online under the Programs Section at www.irvineinline.com

ZERO ToleranceAny conduct unbecoming of the game or any fighting from players or participants, will NOT be tolerated andwill result in automatic expulsion of tournament participation at the discretion of the tournament directors.

Registration FeeAll Registration Fees must be paid in full prior to October 26th, 2012

November 2-4, 2012The Rinks Irvine Inline - Irvine, CA

TOURNAMENT RULES


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Share YourHockey With A HeartSpirit with our community through your contributions andpay-it-forwardto children and those in need who this event strives to benefit. This year we have raised the bar againIn our 6th year, we hope to host 95 teams in the tournament. Weve announced new divisions and events. TheAnaheim Ducks will be promoting the events in radio and television interviews. Players will be there as wilWild Wing, and the Power Players. There will be lots of fun things going on, but most importantly we will reachthe 1000th pint mark in our blood drive, and we hope to reach the $225,000 level in total donations to CHOCChildrens Hospital. It is an exciting time!

If you, your team, your Company or a company you know, would also like to make a donationto this event, please complete the form below. No Donation is Too Big or Too Small to Help!

Please check or enter as applicable to describe your donation:

YES. I/we would like to contribute: With Cash, Check or Credit Card In the Amount of $

With Goods or Services Valued at $

Describe:

Your Name or Contact

Company Name

Address

City State Zip

Home Phone Cell Phone

EMAIL (required)

Please Charge My: (Enter one: Visa, MasterCard, American Express) Enclosed is my check

Card # Exp.

Name on Card

Billing Address

City State Zip

Signature

Please make checkpayable to:

CHOC Foundation

Tax ID# 95-6097416

No Donation is Too Bigor Too Small to Help!

Corporate Sponsors:Dale Quayle (714) 330-1602Food VendorsPeggy Quayle (714) 307-1980Fundraising Chair:Traci Strale (949) 910-9886Non-Food Vendors/Exhibitors:Julie Ruff(714)-318-7788

Please email this form to:

[email protected]

To learn more aboutCompany Sponsorship and

Exhibitor or Vendoropportunities at this event,please contact one of our

organizers for more details


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THE RINKS

1. CONSENT, INDEMNIFICATION, WAIVER AND RELEASE AGREEMENT (ADULT)

FOR AND IN CONSIDERATION of my (the undersigned) in activities at and the use of any of the premises and facilities

commonly known as The Rinks - Huntington Beach Inline, The Rinks Corona Inline and/or The Rinks Irvine Inline and any

equipment supplied to me in connection therewith (collectively, Participation), to the fullest extent permitted by applicable laws, I

agree as follows:

1. I acknowledge and I am aware of the hazards, dangers and risks (inherent or otherwise) in connection with the

Participation, including, without limitation, property damage, property loss, property theft, economic loss, accident, minor injury or

serious injury (known or unknown), which may include permanent disability or paralysis, or death to myself, to other participants, to

spectators or other third parties. I further acknowledge that there are natural factors and occurrences which may impact or affect the

safety of the Participation. I warrant that I am in good health and have no physical conditions that would prevent me from acting in

connection with the Participation. I assume full responsibility for, and all risk of, any accident, bodily injury, death, property

loss, property theft or property damage that may result for any reason, including by acts of negligence, in connection with the

Participation, whether caused by The Rinks, Huntington Beach Roller Rink, LLC, Corona Roller Rink, LLC, Irvine Roller

Rink, LLC, and/or Htmurch, LLC and/or each of their respective parent, related, affiliate and subsidiary companies (and

their respective owners, officers, directors, employees or agents) (collectively, the Releasees), me, any third persons or

otherwise.

2. If I become injured or ill as a result of the Participation, I authorize the Releasees to administer, or cause and consento the administration of, whatever first aid, medical care, dental care or other treatment and medications as may be necessary under the

circumstances, including treatment by a physician, emergency medical technician, dentist or hospital (Treatment), although I

acknowledge that the Releasees have no obligation to do so and that the Releasees do not endorse the services of any physician or

hospital that may provide such Treatment. I understand that the Releasees will have no obligation to pay any such costs of any

Treatment and agree to reimburse the Releasees for any such costs incurred.

3. I RELEASE, AGREE NOT TO SUE AND AGREE TO INDEMNIFY AND HOLD HARMLESS THE

RELEASEES of and from any and all claims, causes of action, suits, demands, damages, losses, liabilities, costs, expenses and

any actions of any kind whatsoever (collectively, "Claims"), known or unknown, existing now or in the future, that I, my heirs

executors, administrators, next of kin, assigns or any third party may now or hereafter have against the Releasees, arising in any wayas a result of or in connection with the Participation and any Treatment, including, without limitation, any property damage, property

loss, property theft, bodily injuries, disability, death or other damage suffered by me, my heirs, executors, administrators, next of kin

and assigns or any other party and regardless of any fault or passive or active negligence on the part of the Releasees, myself or any

third party. I expressly waive and relinquish all rights and benefits afforded by California Civil Code Section 1542 and do sounderstanding and acknowledging the significance of this specific waiver of Section 1542. Section 1542 states as follows:

A GENERAL RELEASE DOES NOT EXTEND TO CLAIMS WHICH THE CREDITOR DOES NOT KNOW OR

SUSPECT TO EXIST IN HIS OR HER FAVOR AT THE TIME OF EXECUTING THE RELEASE, WHICH IF KNOWN

BY HIM OR HER MUST HAVE MATERIALLY AFFECTED HIS OR HER SETTLEMENT WITH THE DEBTOR.

4. I grant to the Releasees a non-exclusive license to use my likeness, image, photograph and/or name in connection

with the marketing, promotion and/or advertising of The Rinks (including, without limitation, The Rinks - Huntington Beach Inline

The Rinks - Corona Inline and/or The Rinks Irvine Inline) and/or the Anaheim Ducks in any media known and unknown or

hereinafter developed without geographic or time restrictions.


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THE RINKS

CONSENT, INDEMNIFICATION, WAIVER AND RELEASE AGREEMENT

(Adult)

(PAGE 2)

5. This Agreement constitutes my entire understanding regarding the subject matter of this Agreement and supersedes

any prior statements, agreements or representations (written or oral) regarding that subject matter. No oral representations, statements

or inducements apart from this Agreement as written have been made to me. I agree that this Agreement is intended to be as broad and

inclusive as is permitted by the law of the State of California and that if any portion thereof is held invalid, such invalidity will not

affect any other provision that can be given full effect without the invalid provision. The laws of the State of California shall apply to

and govern this Agreement, without regard to conflicts of laws principles, and I consent to the jurisdiction and venue of the federal,

state and local courts located in Orange County, California.

6. I have carefully read this Agreement, and I know and understand what it means, including that it is a complete

waiver and release of liability and promise to indemnify and not to sue or make a claim. My signature below is my own free and

voluntary act and I intend this Agreement to be legally binding on me. I certify that I am at least 18 years old.

Signature: ____________________________ Date: __________________, 20___

Print Name:________________________________________________________

Cell Phone #:(_____)_______________ Alt. Phone #:(_____)_______________

Address:______________________________________________________________


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THE RINKS

CONSENT, WAIVER INDEMNIFICATION AND RELEASE AGREEMENT (MINOR)

FOR AND IN CONSIDERATION of the child whose name is written below (My Child) participation in activities at and

use of any of the premises and facilities commonly known as The Rinks Huntington Beach Inline, The Rinks Corona Inline and/or

The Rinks Irvine Inline (including transportation to and from) and any equipment supplied to My Child or used by My Child in

connection therewith (collectively, Participation), to the fullest extent permitted by applicable laws I agree as follows:

1. I acknowledge and I am aware of the hazards, dangers and risks (inherent or otherwise) in connection with the

Participation, including, without limitation, property damage, property loss, property theft, economic loss, accident, minor injury orserious injury (known or unknown),, which may include permanent disability or paralysis, or death to myself, My Child, to other

participants, to spectators or other third parties. I further acknowledge that there are natural factors and occurrences which may

impact or affect the safety of the Participation. I warrant that My Child is in good health and have no physical conditions that would

prevent My Child from being involved in the Participation. I assume full responsibility for, and all risk of, any accident, bodily

injury, death, property loss, property theft or property damage that may result for any reason, including by acts o

negligence, in connection with the Participation, whether caused by The Rinks, Huntington Beach Roller Rink, LLC, Corona

Roller Rink, LLC, Irvine Roller Rink, LLC and/or Htmurch, LLC and/or each of their respective parent, related, affiliate and

subsidiary companies (and their respective owners, officers, directors, employees or agents) (collectively, the Releasees),

myself, My Child, any third persons or otherwise.

2. If My Child becomes injured or ill as a result of the Participation, I authorize the Releasees to administer, or cause

and consent to the administration of, whatever first aid, medical care, dental care or other treatment and medications as may be

necessary under the circumstances, including treatment by a physician, emergency medical technician, dentist or hospital

(Treatment), although I acknowledge that the Releasees have no obligation to do so and that the Releasees do not endorse the

services of any physician or hospital that may provide such Treatment to My Child. I understand that I will be financially responsible

for the cost of any such care, treatment or medication and that the Releasees will have no obligation to pay any such costs of any

Treatment and agree to reimburse the Releasees for any such costs incurred.

3. I RELEASE, AGREE NOT TO SUE AND AGREE TO INDEMNIFY AND HOLD HARMLESS (ON

BEHALF OF MYSELF AND MY CHILD) THE RELEASEES of and from any and all claims, causes of action, suits,

demands, damages, losses, liabilities, costs, expenses and any actions of any kind whatsoever (collectively, "Claims"), known orunknown, existing now or in the future, that I, My Child, our respective heirs, executors, administrators, next of kin, assigns or any

third party may now or hereafter have against the Releasees, arising in any way as a result of or in connection with the Participation

and any Treatment, including, without limitation, any property damage, property loss, property theft, bodily injuries, disability, death

or other damage suffered by me, My Child, our respective heirs, executors, administrators, next of kin and assigns or any other party

regardless of any fault or passive or active negligence on the part of the Releasees, myself, My Child or a third party. I (on behalf of

myself and My Child) expressly waive and relinquish all rights and benefits afforded by California Civil Code Section 1542 and do sounderstanding and acknowledging the significance of this specific waiver of Section 1542. Section 1542 states as follows:

A GENERAL RELEASE DOES NOT EXTEND TO CLAIMS WHICH THE CREDITOR DOES NOT KNOW OR SUSPECT TO

EXIST IN HIS OR HER FAVOR AT THE TIME OF EXECUTING THE RELEASE, WHICH IF KNOWN BY HIM OR HER

MUST HAVE MATERIALLY AFFECTED HIS OR HER SETTLEMENT WITH THE DEBTOR.

4. I grant to the Releasees a non-exclusive license to use the likeness, image, photograph and/or name of me and My

Child, in perpetuity, in connection with the marketing, promotion and/or advertising of The Rinks (including, without limitation, The

Rinks Huntington Beach Inline, The Rinks Corona Inline and/or The Rinks Irvine Inline) and/or Anaheim Ducks in any media

known and unknown or hereinafter developed without geographic or time restrictions.


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THE RINKS

CONSENT, INDEMNIFICATION, WAIVER AND RELEASE AGREEMENT

(Minor)

(PAGE 2)

5. This Agreement constitutes my entire understanding regarding the subject matter of this agreement and supersedes

any prior statements, agreements or representations (written or oral) regarding that subject matter. No oral representations, statements

or inducements apart from this Agreement as written have been made. I agree that this Agreement is intended to be as broad and

inclusive as is permitted by the law of the State of California and that if any portion thereof is held invalid, such invalidity will not

affect any other provision that can be given full effect without the invalid provision. The laws of the State of California shall apply to

and govern this Agreement, without regard to conflicts of laws principles, and I and the Releases consent to the jurisdiction and venueof the federal, state and local courts located in Orange County, California.

6. I have carefully read this Agreement, and I know and understand what it means, including that it is a complete

waiver and release of liability and promise on behalf of myself and My Child to indemnify and not to sue or make a claim. Mysignature below is my own free and voluntary act and I intend this Agreement to be legally binding on me. I certify that I am at leas

18 years old.

7. I represent that I am a parent and natural guardian or legal guardian of the child named below and that I am, in fact

acting in such capacity and agree to save and hold harmless and indemnify the Releasees from all claims, suits, demands, damages,

losses, liabilities, costs, expenses and any actions whatsoever, whether known or unknown, which may be made against the Releasees

because of any defect in or lack of such capacity to so act and hereby release the Releasees on behalf of the child listed below andhis/her parent(s) or other legal guardian(s).

Name of Child: _______________________________________ Date of Birth_______________________

Signature of Parent/Guardian: ____________________________________________________________

Print Parent/Guardians Name: _____________________________________Date: ___________, 20____

Address: _____________________________________________________________________________

Cell Phone #:(______)___________________________ Alt. Phone #: (______)_____________________

Emails: ______________________________________________________________________________

School Attending: ______________________________________________________________________

gbph2012 registration packet

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