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B Registration Form - RAMP Interactive

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					         ALBERTA LACROSSE ASSOCIATION/ROCKY MOUNTAIN LACROSSE LEAGUE
                              PLAYER REGISTRATION
 BOX LACROSSE CLUB REGISTERED                DATE OF BIRTH            PLACE OF BIRTH
       IN PREVIOUS YEAR                         MONTH                        DAY                       YEAR




SURNAME:                                            GIVEN NAME(S):
STREET ADDRESS                                      ALBERTA HEALTH CARE NUMBER
CITY                                                HOME PHONE
POSTAL CODE                                         CELL PHONE
EMAIL ADDRESS

   I HEREBY CERTIFY AND AGREE TO CARRY OUT FULLY ALL RULES AND REGULATIONS OF THE PROVINCIAL
           GOVERNING BODY, THE PROVINCIAL ASSOCIATION, C.L.A AND CLUB/ORGANIZATION.

WAIVER AGREEMENT - In consideration of this application to play under the auspices of the RMLL, I do hereby for
myself, parent or guardians, heirs Executors, administrators and assigns, remise, release and forever discharge the RMLL,
its officers, successors, member associations and any one acting on their behalf from all manner of litigation, damage
claims or demands in law or in equity which may have or acquire by reason of personal injury (including death) to myself,
loss or damage to myself or property resulting from any cause whatsoever including without limitation the negligence of
the RMLL, ALA, its officers, successors, member associations and anyone acting on their behalf, which may occur during
or by reason of my participating in games under its durisdiction. I also agree to allow the RMLL and ALA to disclose of
personal information to individuals requiring it for draft purposes in subsequence years.


       THIS CERTIFICATE HAS BEEN ISSUED AT THE DISCRETION OF THE LEAGUE/ASSOCIATION AND MAY BE
                                     SUSPENDED BY THEM FOR CAUSE.

          I ACKNOWLEDGE THAT I HAVE BEEN INFORMED OF THE EXTENT AND LIMITATIONS OF THE
             MEDICAL/DENTAL INSURANCE COVERAGE PROVIDED BY THE LEAGUE/ASSOCIATION
PLAYER SIGNATURE                                    PARENT OR GUARDIAN SIGNATURE (IF PLAYER IS A MINOR)

DATE                                                DATE

TEAM OFFICIAL SIGNATURE                             LACOKA LACROSSE REGISTRAR SIGNATURE

DATE                                                DATE


                                     EMERGENCY CONTACT INFORMATION
PARENT'S NAME:                                      PHONE #1                               PHONE #2
EMAIL ADDRESS:
PARENT'S NAME:                                      PHONE #1                               PHONE #2
EMAIL ADDRESS:
GUARDIAN'S NAME:                                    PHONE #1                               PHONE #2
EMAIL ADDRESS:
                                     COST OF PROGRAM
REGISTRATION FEES (PER PLAYER)                     Jr. B Tier III - $425.00
NON REFUNDABLE FEE:                                $100
ANY OUTSTANDING FEES:                              $
TOTAL OWING:                                       $
PAID:                                              $
POST DATED CHEQUE-
DATE:_____________________________                     $_________________ AMOUNT
                                                       CASH
FORM OF PAYMENT:
                                                       CHEQUE




             LACOKA LACROSSE ASSOCIATION
                                         BOX 4704
                                      PONOKA, ALBERTA
                                          T4J 1S4
                              Web Site: www.lacokalacrosse.com

				
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posted:10/23/2011
language:English
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