MEMBERSHIP FORM January 1st to December 31st, 2016 Name_ 7 Parent/Guardian _ et Address saree City Postal a Email__ __Phone: Residence Cell You must be a current member ofthe Alberta Equestrian Federation (AEF) to become a member of Polocrosse Calgary My AEF #is or lam a member of another Polocrosse Association that carries proper insurance. (Association name and Foreign players must provide copies of any documents they hold showing they are members in good standing in their country. New Players: After 4 games, jackpots or practices new players must become a member of Polocrosse Calgary. (Until they are members, they are not eligible to play in tournaments.) They must sign the “Acknowledgement of Risk and Legal Liability” form provided by Capri Insurance and are encouraged to have their own personal insurance coverage. Medical Information Ifyou require medical care or transportation is required and normal permission is not available in a timely manner, the Undersigned authorizes appropriate medical care as deemed necessary by emergency medical personnel, a physician, or a medical facility. Ambulances or medical personnel are not generally on site and may take 15 minutes or longer to arrive. Date of Birth Emergency Contact ____ Phone # Medical Conditions which emer, AHC#__ ___ Family Physician ___ Phonet# Rules and Regulations for the Polocrosse Field Waivers must be signed and dues submitted before any horse activities commence. Individuals are responsible to personally inspect fields and surroundings each and every time prior to play. Abstain from alcohol consumption prior to or during games, practices, clinics or demonstrations. Treat all officials, players and horses with respect and faimess and address disagreements through the proper channels. * Invited guests are the responsibility of the person who invited them; they must make guests aware of rules, get waivers signed and collect any dues required. * Dogs must be under the care and control of the owners or designated caretakers, if left unattended they must be ied up. Dogs will not be tolerated on the playing field‘* Children are to be under parental or guardian care at all times. It is the responsibility of the parent or guardian to ensure their safety. ‘* Participants in Polocrosse play must wear approved protection helmets and proper riding boots and adhere to all other safety equipment as laid out in the International Rule Book. ‘+ The International Rule Book of Polocrosse will be followed; itis the members’ responsibility to learn and follow the rulebook. ‘* Strive to excel in Horsemanship, Sportsmanship and Companionship. These are the key ingredients that make this sport enjoyable! 1 AGREE to Medical Care & the Release of Medical Inform: ion if a medical emergency should arise, AND I AGREE to abide by the Rules and Regulations of Polocrosse Calgary. Signature Witness Date __ Lam the parent or guardian of » 4 minor, and on the Child’s behalf, and on my behalf, and on the behalf of all other parents and guardians of the Child in consideration of said Child’s participation in or attendance at any Polocrosse practice or game or any related activity, I accept the release and waiver of liability above as an inducement for allowing the Child to participate in Polocrosse games, practices or related activities or attending of the same. Guardian Name _ Guardian Signature __ Date Membership Fees Individual Membership $100 Family Membership — Max 5 Members — Youth Must Be Under 21 $250 Non — Riding Membership $25 One Day Fee- Tournaments, Jackpots & Practices (additional fees may apply) $25 Fundraising Opt Out Fee $100 Late Fee ~ After March 31 $50 Fundraising Fees [Highway Clean-Up Post Dated Cheque per Player ~ May 15th, 2016 $50 Wine Raffle Post Dated Cheque per Player — December 15", 2016 $50 For Office Use: Total Fee Paid Date Paid Paid by: Cash Cheque # Postdated Cheque HCU # WR# Received by: