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Miracle League of Lake Placid 2009 REGISTRATIONwww.miracleleagueoflakeplacid.com
Players Name Home Phone
Street Address City County State Zip Code
________________________________ Parent / Guardian e-mail
Contact Numbers: ______________ ______________ _____________ Work Home Cell
M/F_______ Birthday Age_______ School
Diagnosis Special Needs or Requirements
Wheelchair Walker Other
Players Shirt Size Youth S M L XL Adult: S M L XL XXL (please circle one)
Players Pant Size Youth S M L XL Adult: S M L XL XXL (please circle one)
I give authorization for my child or myself__________________________________ to participate in The Miracle League of Lake Placid, and do hereby release of any liability for injury that may occur while participating as a player or spectator during the season. 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.
Athlete Name Athlete 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 and Phone Number:
Fears/Phobia’s:_______________________________________________________________________________
___________________________________________________________________________________________
Return completed form to: Miracle League of Lake Placid
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