Note: This Statement MUST be signed by parent or guardian, for a minor and by coach or administrator for himself / herself.

I, the parent/guardian of the registrant, a minor, or adult registrant of legal age, agree that I and the registrant will abide by the rules of Xtreme Sports. Recognizing the possibility of physical injury associated with sports activities and in consideration for Xtreme Sports accepting the registrant for their sports programs and activities (the "Programs"), I hereby release, discharge and / or otherwise indemnify Xtreme Sports, their affiliated organizations and sponsors, employees and associated personnel, against any claim by or on behalf of the registrant as a result of the registrant's participation in the Programs.

Parent / Guardian Signature:

Date:

League Participating In:         Lacrosse                   Field Hockey                   Soccer                  

Registrant's Signature:

Registrant's Name (please print):

Address:

Phone Number:

Age:

E-Mail Address:

If you have any questions, please call Jay at 215-672-1175 or e-mail Jay at: xtreme354@aol.com.