Register Form

Player's Full Name*

First NameLast Name

Date of Birth*

Date

AGE*

Gender*

MaleFemale

Ethnicity *

Phone Number*

Area CodePhone Number

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Zip Code*

Parent 1*

Name, Phone, E-mail, Occupation

Parent 2*

Name, Phone, E-mail, Occupation

MEDICAL RELEASE - The purpose of the below listed information is to ensure that medical personnel have details of the medical problem which may interfere with or alter treatment.

In case of emergency, if family physician cannot be reached, I hereby authorize my child to be treated by Certified Emergency Personnel (i.e. EMT, First Responder, E.R. Physician, etc.)*

In case of Emergency, Contact*

Name, Number, Relationship to Player

Family Physician - Name and Number*

Hospital Preference

Please click the drop down menu for SPORTS SELECTION*

YEARS OF ASK TAEKWONDO

DATES ATTENDING BOWLING

Bowling Bumpers

Previous Team (Baseball ONLY)*

Participation Shirt Size IF NEEDED*

Diagnosis*

Medication*

Dosage*

Frequency of Dosage*

Insurance Carrier*

Policy Number*

Date*

Date

WAIVER OF LIABILITY AND HOLD HARMLESS AGREEMENT 1. In consideration for participating in Adaptive Sports for Kids and other valuable consideration, I hereby RELEASE, WAIVE, DISCHARGE AND COVENANT NOT TO SUE Adaptive Sports for Kids, Inc., the Board of Directors, their officers, servants, agents, and employees (hereinafter referred to as RELEASES) from any and all liability, claims, demands, actions and causes of action whatsoever arising out of or related to any loss, damage, or injury, including death, that may be sustained by me, or to any property belonging to me, WHETHER CAUSED BY THE NEGLIGENCE OF THE RELEASEES, or otherwise, while participating in such activity, or while in, on or upon the premises where the activity is being conducted or in transportation to and from said premises. 2. To the best of my knowledge, I can fully participate in this activity. I am fully aware of risks and hazards connected with the activity, including but not limited to the risks as noted herein, and I hereby elect to voluntarily participate in said activity, and to enter the above-named premises and engage in such activity knowing that the activity may be hazardous to me and my property. I VOLUNTARILY ASSUME FULL RESPONSIBILITY FOR ANY RISKS OF LOSS, PROPERTY DAMAGE OR PERSONAL INJURY, INCLUDING DEATH, that may be sustained by me, or any loss or damage to property owned by me, as a result of being engaged in such activity, WHETHER CAUSED BY THE NEGLIGENCE OF RELEASEES or otherwise. 3. I further hereby AGREE TO INDEMNIFY AND HOLD HARMLESS THE RELEASEES from any loss, liability, damage or costs, including court costs and attorney's fees, that may incur due to my participation in said activity, WHETHER CAUSED BY NEGLIGENCE OF RELEASEES or otherwise. 4. It is my express intent that this Release and Hold Harmless Agreement shall bind the members of my family and spouse (if any), if I am alive, and my heirs, assigns and personal representative, if I am not alive, shall be deemed as a RELEASE, WAIVER, DISCHARGE AND CONVENANT NOT TO SUE the above named RELEASEES. I hereby further agree that this Waiver of Liability and Hold Harmless Agreement shall be construed in accordance with the laws of the State of Texas. 5. I UNDERSTAND THAT ADAPTIVE SPORTS FOR KIDS, INC. WILL NOT BE RESPONSIBLE FOR ANY MEDICAL COSTS ASSOCIATED WITH AN INJURY I OR MY CHILD MAY SUSTAIN. IN SIGNING THIS RELEASE, I ACKNOWLEDGE AND REPRESENT THAT I have read the foregoing Waiver of Liability and Hold Harmless Agreement, understand it and sign it voluntarily as my own free act and deed; no oral representations, statements or inducements, apart from the foregoing written agreement, have been made; I am at lease eighteen (18) years of age and fully competent; and I execute this Release for full, adequate and complete consideration fully intending to be bound by same. *

VERY IMPORTANT! Sign up for Text Message Alerts! Simply Text @adaptives to 81010

OR

@adaptives to

(536)265-6842

You will receive a text message asking for your name. Simply reply with your “name” (i.e., Kerri May) and you will start receiving notifications.

Did you sign up to receive Text messages from Remind?*

Adaptive Sports for Kids was formed in December, 2011. Our goal is to give children and young adults with disabilities the opportunity to play sports they may not otherwise be able to play, all at no charge to them. Since many of our players are in wheelchairs, walkers, or just have balance issues, certain equipment is needed in order to give them the chance to play. We rely strictly on donations to supply this special equipment. We are Chapter 501 (c )(3) tax exempt.

Adaptive Sports For Kids Registration Form