Tel: (204) 925-5668                                   200 Main Street,                           e-mail:info@mbbroomball.com   

Fax: (204) 925-5703                                 Winnipeg, MB  R3C 4M2               Website:www.mbbroomball.com

Registration Year __________

Forms including applicable fees (cheques payable to MABA) must be received by December 31^st

Please print – Only legible forms will be accepted.  Fee: $30.00

SURNAME: ________________________ GIVEN NAME: _________________________________

MAILING ADDRESS: ____________________________________ CITY: _____________________

PROVINCE: ____________________   POSTAL CODE: _________________________

Telephone #: ______________________________ (hm)______________________________(b)

E-mail: __________________________________________________________________

GENDER: Male ________   Female _______   Date of Birth: _____day ______ month ______year

PROVINCIAL HEALTH NUMBER: ______________________________

                                                             6 digits

REGISTRATION CATEGORY:   Please complete all applicable information

Player__________               Coach _______   Level _______

Associate: ___________       Official_______   Level _______

Administrative team members

Waiver:

I hereby declare that my participation in the sport of Broomball is voluntary and I assume and accept all risks associated within.  I also declare that I remise, release and forever discharge and by these presence do for myself, my heirs, executors, administrators and assigns, remise, release and forever discharge the Canadian Broomball Federation and also the Manitoba Amateur Broomball Association or team affiliated with said corporate associations, their directors, officers, employees, agents, volunteers, from any and all manner of actions, cause and cause of actions, suits, debts, sums of money, damages, claims and demand whatsoever at law or at equity which I ever had, or now have, or which I, or my heirs, executors, administrators, or assigns hereafter can, shall or may have by reason of any matter, cause or thing whatsoever existing as a result of personal injury, death, property damage, or lose sustained by me in consequence of my participation in the sport of Broomball.

Applicant Signature: ________________________________________ Date: _________________

Parent/ Guardian Signature: __________________________________ Date: _________________

For applicant under 18 years of age

Witness Signature: _________________________________________ Date: ________________

FOR OFFICE USE ONLY:

Date Received: ______________________________________ Paid by: Cheque _______ #_________________

Registration #:_________________________________