Bellmore Merrick Roller Hockey PO Box 523 North Bellmore, New York 11710 Email: [email protected] Website: www.bmrhockey.com

Bellmore Merrick Roller Hockey Registration Form 2016‐2017 Fall/Winter Season PLAYER INFORMATION Last Name: ______First Name: ______Street Address: ______Town, State, Zip: ______Home Phone: ______Email Address: ______Date Of Birth: ______Age as of 9/1/2016: ______School: ______Grade: ______Goalie: Yes  No  PARENT/GUARDIAN INFORMATION Name: ______Phone: ______Name: ______Phone: ______May we contact you about coaching? Yes  No  Assisting? Yes  No  I, the Parent or Guardian of the above named child, hereby give my approval of his/her participation in any of the activities of the Bellmore Merrick Roller Hockey League during the current season. I assume all risks and hazards incidental to this activity, and transportation to and from the activity. I do further indemnify and hold harmless, Bellmore Merrick Roller Hockey, the organizers, supervisors, coaches and sponsors, from any and all claims resulting in connection with my child’s participation, including but not limited to, personal injury, wrongful decision, death or dismemberment. I further certify that I am the parent or legal guardian of the above named applicant and all of the above information is true to the best of my knowledge. For the purpose of keeping teams competitive, a player whose skills far exceed those of other players in his/her division may be asked to “play up” in the next division any time, at the discretion of the Bellmore Merrick Roller Hockey League officials.

Parent/Guardian Signature: ______Date: ______

Registration fee includes all insurance costs and the cost of a new Hockey for each player. First Player: $160; Second Player: $120; Additional Players: $75 Due to organizational operating expenses there can be no refunds of Registration Fees. ** There is a $30.00 Fee for All Returned Checks **

MANDATORY EQUIPMENT Hockey * (Full face shield) Mouth Guard ** Roller Hockey Skates Hockey Gloves (No Gloves) Elbow Pads Athletic Cup (Boys) Hockey Stick (Butt End Taped) Shin Guards Pelvic Protector (Girls) (To be worn over equipment) /Chest Protector (Strongly recommended)

*All players MUST be wearing their helmet when they enter the rink **During play, mouth guard MUST be in the player’s mouth, or they will get a two‐minute minor penalty

ALL PLAYERS ARE ASSIGNED TO TEAM BY DRAFT, EXCEPT FOR SIBLINGS 