Players Name                                                                                                   Home Phone

                                                       _____                                                                                                             

Street Address                                                  City                  County                    State                       Zip Code

                                                                        ________________________________                                           

Parent / Guardian                                                                      e-mail                               Work or Contact Number

M/F_______    Birthday                             Age_______           School                                                                         

Diagnosis                                                                                                                                 

Special Needs or Requirements:                                                                                                    

Wheelchair                               Walker                                     Other                           

I hereby grant the Miracle League of Lake Placid, 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 any 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. I hereby release and forever discharge the Miracle League from any and all liability and damages relating to the use of my name, voice, likeness or any other identifiable representation of me.  I hereby waive any right I may have to inspect or approve the finished materials or any part or element there of 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 Lake Placid to appear in these materials.  I acknowledge that I have fully read and understand this document and that I have had any questions regarding its effect or the meaning of its terms answered to my satisfaction. I certify that I am at least 18 years of age, unless this document is also signed by my parent or legal guardian.

Name                                                                                       Signature                                                                     

Signature of Parent or Guardian                                                                 Minor’s D/O/B_______________   

Name of Parent or Guardian (please print)                                                                                                                    

Diagnosis:

___________________________________________________

Current Prescription and Medications:

___________________________________________________                                                                                              

Allergies:

Primary Care/Physician Phone Number: