Floor Hockey Waiver

Floor Hockey Waiver
Event Name: Floor Hockey
Event Date: September 2026-May 2027, Monday evenings
Event Time: 6 - 8 PM

6-7 PM is designed for children who are ages 7-12. Children under the age of 7 must be accompanied by an adult guardian. By signing this waiver, you agree to this requirement.

7-8 PM is designed for youth who are 13 years and older. Children under the age of 13 must be accompanied by an adult guardian OR receive permission from the volunteers for their child to participate in the floor hockey designed for youth.

I hereby agree and declare that I am the legal parent/guardian of the child/youth. I understand that Bethel Selkirk will do everything within their power to keep my child/youth safe; however, activities may result in physical injury to my child but
nonetheless specifically request that he or she be allowed to participate in those
activities.

By signing this waiver I agree to not hold Bethel Selkirk and/or their volunteers liable for any injuries that may occur as a result of my child/youth participating in the activities at floor hockey. I agree that my child/youth may participate in floor hockey and acknowledge that they play at their own risk.

If the above-named child requires any emergency medical treatment or procedures during the activities, I hereby consent to the activity supervisor(s) to make any decision and take any action to arrange for such procedures or treatments in the discretion of the activity supervisor(s).
Child's Name

First NameLast Name
Age
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender
Parent/Legal Guardian Name

First NameLast Name
Relationship to the Minor
Phone Number 1
Format: (000) 000-0000.
Phone Number 2
Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Does the child have any allergies?
Does the child have any medical conditions that you would like to declare?
Any special instructions?
I, {parentlegalGuardian}, the parent or legal guardian of {childsName}, give my permission to join or participate in the Event stated in this form.
Parent's Signature
Date Signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: