Gulf Coast Middle School 

Registration/Release Form

Emergency Contact Information:

Are there any physical or medical conditions that could be aggravated by participation in this event? (Examples: Asthma, Seizures, Past surgeries, etc If yes, please explain:

Release (Read carefully before signing this form):

I understand that engaging in any form of physical activity involves a risk of personal injury. I am in good physical condition, and I have disclosed all conditions known to me that may impact my ability to participate in this event. I assume the risk of any injury that may result from my participation in activities in the Mississippi Gulf Coast Top 75 Combine & All Star Game, presented by Hot Willie Peppa Show. In consideration for being permitted to participate in such an event, I hereby release, waive, and forever discharge Hot Willie Peppa Show, D'Iberville Sports Complex, and Biloxi High Football Stadium (including its agents, employees, volunteers, and officers) from any claim arising from my participation in this event. Further, I release said parties from any claim arising from any medical treatment rendered to me in connection with my participation in this event. I hereby authorize the staff/volunteers of the Coast Future Stars All Star Game, to act on my behalf during this event in any emergency that may require medical attention.

I understand members of the media may be present during this event and the results of this event may be released to the media. I consent to the use of my name or a video or photographic image of me by Hot Willie Peppa Show or the media reporting on this event. I hereby authorize Hot Willie Peppa Show to use, disclose, and/or publish video or photographic images of the person identified above. I understand that I can revoke this authorization at any time by contacting the Hot Willie Peppa Show. I understand the results also will be posted on the Hot Willie Peppa Show website. I consent to such releases of information relating to me.