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Adult Program Sign Up

Please cleary fill out all fields:
First Name (required, please enter clearly)
Last Name (required, please enter clearly)
Address
City
State
Zip Code
Home Phone
Cell Phone
E-Mail Address
Date of Birth: Day Month Year
Shirt Size:
Does the Player use a walker or wheelchair?
Disability Diagnosis:
Alergies:
Is residency a Group Home?

(If Applicable)
Agency Affiliation:
Program Site:
Program Supervisor:
Program Site Phone Number:
Program Contact E-mail:
Comments:

Release Form

*Mandatory Section
In consideration for the Miracle League of Westchester, Inc. providing the opportunity for this consumer to participate in Miracle League baseball, the undersigned does hereby release and agree to indemnify and hold harmless the Miracle League of Westchester, Inc and its officers and directors from any and all claims for personal injury, death, property damage, or any type of claim or damage (including but not limited to attorney's fees or litigation expenses) resulting from this consumer’s activities in connection with participation in Miracle League baseball or the participation of any family member or guest of the undersigned. We assume all risks and hazards incidental to such participation in Miracle League games and activities and consent for this consumer to receive first-aid and/or emergency care by a qualified Emergency Medical Technician or physician or other person qualified to render medical assistance in the event this consumer suffers an injury during sanctioned games and activities. I agree to provide this consumer’s specific medical information to the Miracle League of Westchester, Inc. so that appropriate precautions and care can be provided to this consumer during sanctioned games and activities. We agree to be present at all games and activities so that w e can manage this consumer’s specific needs. We agree to have any and all medication (prescription and nonprescription) for this consumer and shall be solely responsible for dispensing any such medication to this consumer.
Guardian Name
Date