U.S. Field Hockey Association Membership Application
Please Return with check, credit card information or money order (no cash) payable to
USA Field Hockey, One Olympic Plaza, Colorado Springs, CO 80909

For Secure Online Registration, Click Here
New Member Renewal    Member No.

   
Last Name                                    First Name              Middle Name

Date of Birth   US Citizen  Yes No    Male Female


Address

City   State Zip

Phone Work

Fax e-mail

Credit Card  Expiration Date

Credit Card Number


WAIVER & RELEASE MUST BE SIGNED OR APPLICATION WILL BE RETURNED TO YOU
CODE OF CONDUCT MUST ALSO BE SIGNED WITH THIS APPLICATION 

  

MEMBERSHIP OPTIONS
ATHLETE/UMPIRE/COACH
Youth (U12) $25
U18 $40
Adult (18 and older) $50
Coach HS Coach $50
Umpire* $65
Includes new umpire insurance benefit
OTHER
Life Member $500
Applicants must be 40 years old or older for life memberships
Corporate/Industry $500
Donation to USA Field Hockey
Total
Waiver and release of Liability
Must be completed by ALL members
In consideration of being allowed to participate in any way in the United States Field Hockey Association programs,
related events and activities, the undersigned acknowledges, appreciates and willingly agrees that:

1. I will comply with the stated and customary terms and conditions for participation. If, however, I observe any
unusual significant hazard during my presence or participation, I will remove myself from participation and bring
such to the attention of the nearest official immediately; and

2. I acknowledge and fully understand that each participant will be engaging in activities that involve risk of
serious injury, including permanent disability and death, and sever social and economic losses which may
result not only from their own actions, inactions or negligence but the action, inaction or negligence of others,
the rules of play, or the condition of the premises or of any equipment used. Further, I accept personal responsibility
for   the damages following such injury, permanent disability or death; and,

3. I knowingly and freely assume all such risk, both known and unknown, even those arising from the
negligent acts or omissions of others, and assume full responsibility for my participation; and

4. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, hereby release, hold
harmless the United States Field Hockey Association, its officers, officials, affiliated clubs, their respective administra-
tors, directors, agents, coaches, and other employees of the organization, other participants, sponsoring agencies
advertisers, and , if applicable owners and lessors of premises used to conduct the event, all of which are herein-
after referred to as "releasees," with respect to all and any injury, disability, death or loss or damage to person
or property, whether arising from the negligence of the releasees or otherwise, to the fullest extent permitted by law.

5.I hereby grant permission to USA Field Hockey to use my photograph image or likeness in any or all official USA Field Hockey publications, film, video or official USAFH website(s) without further consideration or compensation. I understand that USAFH retains ownership of all photographs and images and any and all rights to the photographs images in any format or medium.
I have read this release of liability and assumption of risk agreement, fully understand its terms, understand that I
have given up substantial rights by signing it and sign it freely and voluntarily without any inducement.


_______________________________________________________________
Participant's signature (even if under 18)                                                                             Date

For parents/guardians of participants under 18 at time of registration.
This is to certify that I, as parents/guardian with legal responsibility for this participant, do consent and agree to his/
her release, as provided above, of all the Releasees, and, for myself, my heirs, assigns, and next of kin, I release
and agree to indemnify and hold harmless the releasees  from any and all liabilities incident to my minor child's
involvement or participation in these programs as provided above, even if arising from their negligence, to the fullest
extent permitted by law.

_______________________________________________________________
Parent/Guardian Signature                                                                                                      Date

member.app December 2006