Visalia Miracle League Player Registration

SECTION 1:

First Name: Last Name: Gender:

Parent/Guardian: (if applicable)

Mailing Address: City: Zip:

Home Phone: Emergency Phone:

Email Address

Birthdate: Age: Uses Wheelchair: Uses Walker:
mm/dd/yy

Diagnosis:

Shirt Size:

Special Requests:

SECTION 2: TWO RELEASE FORMS TO COMPLETE BELOW
In order to participate you must read and agree with the following releases. Your registration will not be complete unless doing so.

FORM #1 MEDIA RELEASE

MEDIA RELEASE
I hereby grant the Miracle League of Visalia, 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 or my family members including my Miracle League dependent. These materials may appear
in any form, style. Color or medium whatsoever (including photographs, videotapes, films, sound recording, software, drawing,
prints, broadcast, internet, and electronic media.) I agree that all material containing and identifiable representation of m
dependent shall be and remain the sole and exclusive property of the Miracle League of Visalia. I hereby release an forever
discharge the Miracle League of Visalia from any and all liability and damages relating to the use of my dependents name, voice
and any other identifiable representation of me. I have agreed to the above in consideration of the opportunity given to my
dependent by the Miracle League of Visalia to appear in these materials. I acknowledge that I have fully read and understand this document.
I certify that I am at least 18 years of age.

I agree with Media Release?: Yes No
Parent/Guardian or Conservator Name:
Printing your name here indicates an electronic signature and that you have submitted it to the Visalia Miracle League.

FORM #2 VOLUNTEER ( adults 18yrs and older) RELEASE

RELEASE AND INDEMNIFICATION AGREEMENT ( UNDER 18 AND/OR LEGALLY DEPENDENT)

We, the undersigned, are the parents or guardians, or conservator of the above named participant. In consideration for the Miracle
League of Visalia, Inc. (“Miracle League”) providing the opportunity for our child to participate in Miracle League baseball, we
hereby release Miracle League from any and all claims, damage, or injury that we may suffer as a result of our dependent’s
participation in Miracle League baseball. In addition, we hereby agree to indemnify, defend and hold Miracle League and its
officers, directors, volunteers, agents, contractors, supporters, or any other person associated with Miracle League harmless from
any and all claims for loss, damage (including attorneys fees and costs, including, but not limited to experts and consultants fees), liability, death, or injury to the person or property arising from or related to our dependent’s participation in Miracle League
baseball, including, but not limited to , claims by our dependent against Miracle League.

We assume all risks and hazards involved in, or incidental to, our dependent’s participation in Miracle League games and
activities and hereby consent to having out dependent receive first-aid and/or emergency care by a qualified Emergency Medical
Technician or physician in the event that our dependent suffers any injury during Miracle League games or activities.

We agree to provide all pertinent medical information to the Miracle League and to assist Miracle League so that adequate
precautions can be made and so that appropriate care can be provided to our child during Miracle League games and activities.
We agree to have all of our dependent’s necessary medication on hand during all Miracle League activities and to be solely
responsible for administering any such medication to our dependent.

We agree that at least one parent or guardian, if the participant is a player, will be physically present at all times during Miracle League games and activities.

I agree with this Release Agreement?: Yes No
Parent/Guardian or Conservator Name:
Printing your name here indicates an electronic signature and that you have submitted it to the Visalia Miracle League.

By clicking on Submit you are submitting this document as if you were submitting a registration form signed by you to the Miracle League office for the purpose of registration.

After you click on submit you will be directed to the payment page where you will receive instructions
of how you can pay the fee. Please note your Miracle League registration will not be complete until
you pave made the payment for the registration fee.

Need to see the payment page before submitting this form? Click here.