Player Name____________________________Age____D.O.B.________________
Address_______________________Phone________________Cell_____________
E-Mail_________________________________
Emergency Contact_____________________Phone_____________________
_____ Midget (17-Under) @ $145 (10 games + playoffs)
_____ Bantam (13-Under) @$135 (10 games + playoffs)
(Sibling Discount = 2nd child is 20% off)
__I would like to sponsor a team:
______Team jersey sponsor @ $150
Please make check payable to: SUNILAND OPTIMIST CLUB
Consent
I, the undersigned parent or legal guardian of ________________ or as an adult player, do hereby consent
and agree that the above named minor(or adult) may participate in the Suniland Optimist Roller Hockey program. I further agree
that the Suniland Optimist Roller Hockey program, including the Optimist Club, its members, volunteer officials, coaches and
referrees and other support persons, will not be held liable for any accidents which may result from the above-named person's
participation in said league's activities, including, but not limited to, games, practices, travel and/or being a spectator.
It is further agreed that this consent remain in full force and effect until such time as the undersigned parent or legal
guardian (or adult player) shall notify the Suniland Optimist Club, in writing, of the cancellation of the consent.
Parent or legal guardian (or adult player)___________________________________________________
Mail this form, with payment to : Richard Stuck, 13720
SW 90 Ave., F, Miami, FL 33176
