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Orange County Tryout Signup
Complete Form
 
  Player Information
First Name: *   MI:
Last Name: *
Street Address: *
City: *    State: *   Zip: *
Home Phone: *    Cell:
E-Mail Address *
D.O.B:   (mm/dd/yyyy)
Height:   Weight:
Shirt Size: S  M  L  XL
Position: * Offense: Defense: Goalie: Offense/Defense: Goalie/Defense:
   
  Parent Information
First Name: *   MI:
Last Name: *
Street Address: *
City: *    State: *   Zip: *
Home Phone: *    Cell/Work Phone:
E-Mail Address *
   
  Emergency Contacts
1. Full Name : *   Phone: *
2. Full Name :   Phone: *
   
  List any medical problem(s)/physical limitation(s) player has:
 
   
Doctor's Name:   Phone: *
   
 
Please be sure you read and understand the following:
 
PLEASE NOTE: All your personal information will remain confidential. Tryout fee is twenty dollars (cash only). Upon completing your tryout sign-up form you will receive a via e-mail confirmation in the next 5 business days along with your confirmation number. Our coaches are only allowing 30 people to tryout, so please only sign up if you are going to be attending tryouts. Please make sure your parent(s) or legal guardian(s) attend tryouts. In the event you need to cancel, please e-mail us at everettj3333@yahoo.com along with your full name and confirmation number. If you have any questions, please feel free to e-mail us at orangecountypirates@yahoo.com or call us at 714-953-5911(twenty four hours a day seven days a week).
 
DISCLAIMER, ASSUMPTION OF RISK AND WAIVER: 
I, parent/guardian of the above mentioned player, acknowledge that participation in roller hockey necessarily involves travel and including and not limited to: contact with considerable force, risk of severe, permanent physical injury including bruises, scrapes, strains, sprained or torn muscles, tendons or ligaments, broken bones, dislocation of joints, concussion, brain damage, nerve and spinal cord injury, paralysis and death, etc.  I willingly and voluntarily accept and assume all such risk.  I hereby give my consent for emergency medical care prescribed by a Doctor of Medicine or Doctor of Dentistry. 
 
I have read the above and acknowledge the risk and waiver form. I fully understand the terms and conditions of
the above, I agree to release Orange County Pirates Roller Hockey Club and its employees from any and all responsibility in case of an accident or any of the above mention injuries and agree not to file suit against O.C.P.R.H.C., its partners and/or affiliates. By completing this form and submitting it you freely and voluntarily without inducement. 
 
* I have read all above information and I agree to the disclaimer, assumption of risk and waiver.
Parent (s) Full Name:
 
 
 
A.A.U. Certified | Call us: 714-953-5911 | E-Mail: orangecountypirates@yahoo.com
 
 
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