Florida Half Century ASA, Inc

Registration Application Registration Fee: $25.00

Please Type or Print Legibly REVISED: April 15, 2006

Name ____________________________________________________________________ Date __________________

FIRST INITIAL LAST

Permanent Address: ________________________________________________________________________________

City ____________________________________ County __________________ State ________ Zip ____________

TEL NUMBER ______________________________________________________________________________________

Florida Driver’s License or Florida I.D. Number

Date of Birth ___________________________ Where Born ___________________________________________

Month Day Year Country

City _____________________________________________ County _________________________ State __________

Note: Applicants MUST SUBMIT ONE OF THE FOLLOWING DOCUMENTS VERIFYING DATE OF BIRTH: Original Birth Certificate, or Original Certificate Of Birth Registration, or Original Passport (can be expired), or Original Baptismal Certificate. Original Will be Returned to Applicant.

Part Time Florida Residence: How Long? From ________________ To _______________________

Address _____________________________________________ Fla Tel # _________________

City __________________________________ Country ____________________ Zip # ________

Team Affiliation: Toronto Sons of Beaches or _____________________________________

VOLUNTARY DISCLOSURE CONSENT I hereby certify that the above information is correct and I further agree that

the information may be verified through direct contact with the records bureau at the location of my birth or

through the U.S. Immigration and Naturalization Service. Falsification of documentation shall result in denial

of membership.

________________________________________

Signature of Applicant

RETURN WITH CHECK PAYABLE TO: John P. Townley Chairman (954) 426-0335 Ph & Fax

Verification Committee

913 SE 15th Court

Deerfield Beach, FL 33441

OFFICIAL USE ONLY

Date Received____________________________ Date Verified ______________________________

Verified By: B.C. ______ C.B.R .________ P.P .________ Other ________ RECORDS ATTACHED _______________

Yes No

ACCEPTED FOR MEMBERSHIP ___________________________________ BY ________________________________

VERIFICATION CHAIRMAN

F.H.C.A.S.A. MEMBERSHIP NO..

NO TOURNAMENT SITE VERIFICATIONS SIGN WAIVER ON REVERSE SIDE

Florida Half Century ASA, Inc.

WAIVER AND RELEASE OF LIABILITY FORM

I acknowledge that softball or any sporting event is an extreme test of a person’s physical

and mental limits and carries with it the potential of death, serious injury, or property loss.

I HEREBY ASSUME THE RISKS OF PARTICIPATION IN A SOFTBALL EVENT.

I hereby take the following action for myself, my executors, administrators, heirs, next of kin,

successors and assigns:

A WAIVE, RELEASE, AND DISCHARGE from any and all claims of liability for death or personal injury or damages of any kind, EXCEPT THAT WHICH IS THE RESULT OF GROSS NEGLIGENCE AND/OR WANTON MISCONDUCT OF PERSONS OR ENTITIES LISTED BELOW, which arise out of or relate to my participation in, or my traveling to and from the softball event, THE FOLLOWING PERSONS OR ENTITIES: Florida Half century Amateur Softball Association, (known as FHCASA), the Directors, Officers, Team Managers, and players of the FHCASA, the tournament directors, sponsors, and the officers, directors, employees, representatives, and agents of any of the above: b) I AGREE NOT TO SUE any of the persons or the persons or entities mentioned above for any of the claims or liabilities that I have waived, released, or discharged herein; and c) I INDEMNIFY AND HOLD HARMLESS the persons or entities mentioned above from any claims made or liabilities assessed against them as a result of my actions.

OFFICIAL USE ONLY

WAIVER AND RELEASE OF LIABILITY FORM

I acknowledge that softball or any sporting event is an extreme test of a person’s physical

and mental limits and carries with it the potential of death, serious injury, or property loss.

I HEREBY ASSUME THE RISKS OF PARTICIPATION IN A SOFTBALL EVENT.

I hereby take the following action for myself, my executors, administrators, heirs, next of kin,

successors and assigns:

BY SIGNING THIS FORM, I AFFIRM THAT I AM FIFTY (50) YEARS OF AGE or OLDER. I HAVE READ THIS DOCUMENT AND UNDERSTAND ITS CONTENTS.

______________

PRINTED NAME DATE

____________________________________________

SIGNATURE

OFFICIAL USE ONLY

WAIVER AND RELEASE OF LIABILITY FORM

I acknowledge that softball or any sporting event is an extreme test of a person’s physical

and mental limits and carries with it the potential of death, serious injury, or property loss.

I HEREBY ASSUME THE RISKS OF PARTICIPATION IN A SOFTBALL EVENT.

I hereby take the following action for myself, my executors, administrators, heirs, next of kin,

successors and assigns:

BY SIGNING THIS FORM, I AFFIRM THAT I AM FIFTY (50) YEARS OF AGE or OLDER. I HAVE READ THIS DOCUMENT AND UNDERSTAND ITS CONTENTS.

____________________________________________ ______________________________

PRINTED NAME DATE

____________________________________________

SIGNATURE

______________