90 Ashland Ave

							                           90 Ashland Ave. | Winnipeg, Manitoba | R3L 1K6

                          EQUIPMENT PASS REGISTRATION
                                          Consent Form

Pass Holder Name: __________________________ Home #: ___________________________

Parent/Guardian(if applicable): ___________________________________________________

Address: ______________________________________________________________________

Postal Code: ____________________________ Cell #: ________________________________

Email: _______________________________________________________________________

ID: _____________________________________ (applicants over the age of 18)

Equipment passes are free and are available to any member of the public. Individual passes are
required for anyone wishing to access the Community Center’s equipment. We ask that the pass
holder check out only equipment that will be used in their stay. Equipment available with a pass:

       Rock Band equipment (Guitars / Drum Kit / Microphone)
       Playstation games, Movies
       Soccer Balls, Footballs, Volley Balls, Basketballs, Dodge Balls
       Hula Hoops, Frisbees, Water Guns
       Tennis, Badminton and Ping Pong Rackets
       Baseball Gloves & Bats
       Floor/Ice Hockey Equipment (sticks/skates – subject to availability of facility)
       Computer/Internet Access
       (tennis balls, baseballs and pucks are available for a $1.00 refundable deposit)

I hereby apply for access to Riverview Community Center’s equipment, to be used only on the
property. I understand that I am responsible for all equipment checked out and that if lost, stolen
or damaged, that I am financially liable for any equipment in my care.

Signature: _______________________________ Date: ________________

(Parent or Guardian’s signature required for children/youth under the age of 18)



Internal Use Only:

Verified: ________________________________ Signature: _________________________

Equipment Pass #: ___________________________________ Date Issued: ________________