First Name
Last Name
Address
City
State
Zip Code
Telephone
Date of Birth
Age
Parent/Guardian Name
Parent Cell Number
Parent E-Mail
Emergency Contact #
Disability Diagnosis
Alergies
Shirt Size
Is the player ambulatory?
Does the player require a walker or wheelchair?
Communication Skills
Game Day and Time Preference:
Comments:
2010 Release Form *Mandatory Section
In
consideration for the Miracle League
of Westchester, Inc. providing the opportunity for my child 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 my child's activities in connection
with
participation
in Miracle League
baseball or the participation of any family member or guest of the
undersigned.
I assume all
risks and hazards
incidental to such participation in Miracle League games and activities
and
consent for my
child 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 my child suffers an
injury
during sanctioned games and activities.
I agree to
provide my child's specific
medical information to the Miracle League of Westchester, Inc. so
that
appropriate precautions and care
can be provided to my child during sanctioned games and activities.
I/We agree to
be present at all games
and activities so that I/W e can manage our child's specific needs. I
agree to have
any and all medication
(prescription and nonprescription) for my child and shall be solely
responsible for
dispensing any such
medication to my child.
Parent/Guardian
Date
2010 Photo Release Form *Optional Section
I/We
understand that there will be
media and promotional coverage of Miracle League Games and activities
and I/We
give our consent to publish my/our child's name and picture for such
purposes.
I hereby grant the Miracle League of Westchester, Inc., its affiliates,
franchises, advertising and promotional agencies, and their agents, the
irrevocable, unrestricted right to use, publish, display and distribute
materials bearing my name, voice, likeness or any other identifiable
representation of myself, my family members, including my Miracle
League
player/child. These materials may appear in any form, style, color or
medium
whatsoever (including, without limitation, photographs, video tapes,
films,
sound recordings, software, drawings, prints, broadcast, internet and
electronic media). I agree that all material containing identifiable
representation of me (including without limitation, all negatives,
plates and
masters of any photographs, files, prints or tapes) shall be and remain
the
sole and exclusive property of the Miracle League of Westchester. I
hereby
release and forever discharge the Miracle League of Westchester, Inc.
from any
and all liability and damages relating to my name, voice, likeness or
any
identifiable representation of me. I hereby waive any right I may have
to
inspect or approve the finished materials or any part or element
thereof that incorporates
my name, voice, likeness or any other identifiable representation of
myself, my
family, including my Miracle League player/child. I have agreed to the
above in
consideration of the opportunity given to me by the Miracle League of
Westchester, Inc. to appear in these materials.
Parent/Guardian
Signature
Date
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