Fall 2005

Player Name____________________________Age____D.O.B.________________

Address_______________________Phone________________Cell_____________

E-Mail_________________________________ Today's Date__________________

Emergency Contact_____________________Phone_____________________

_____Adult Team @$1,000 _____Individual @$125

_____High School Team @ $1,350

_____High School Individual @ $165

_____13-15 @$165 

_____12-Under @$155

 ____9-Under @$155

(Sibling Discount = 2nd child is 15% off)

__I would like to sponsor a team and/or place an ad on the rink boards.

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