Game 3 Registration - Miracle League of Western Massachusetts

Parent/Guardian First Name

Parent/Guardian Last Name

Email

Address

City

State

Zip Code

Phone/Mobile

Player First Name

Player Last Name

Date of Birth

Gender

Female

Male

T-Shirt Size

Diagnosis

Does your child use a wheelchair or other mobility device?

Is there anything specific that your child would like to work on?

Additional comments/questions/concerns:

First Name

Last Name

Phone/Mobile

Liability Waiver

I give authorization for my child to participate in The Miracle League of Western Massachusetts, Inc. and do hereby release of any liability for injury that may occur while participating as a player or spectator during the season. Parent and/or Guardian must be present at all Miracle League Games and/or events.

Media Release

I hereby grant the Miracle League of Western Massachusetts, 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 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 of Western Massachusetts, Inc. I hereby release and forever discharge the Miracle League of Western Massachusetts, Inc. 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 of Western Massachusetts, Inc. player. After the uniforms have been ordered there will be NO REFUNDS due to the customization of the uniform shirts.

Authorization Acknowledgment

I have agreed to the above in consideration of the opportunity given to me by The Miracle League of Western MA, Inc. 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.

Registration Payment

Cost: $30.00

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Game 3

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Game 3