NW Association for Blind Athletes

Participant Registration Form

Country
State / Province*
Address
City
Email*
Confirm Email*
Cell Phone*
Home Phone Number
Favorite Sport and Recreational Interest
Vision*
  • B1 - totally blind
  • B2 - best corrected vision is 20/600 and up
  • B3 - best corrected vision is 20/200 - 20/599
  • B4 - best corrected vision is 20/70 - 20-199
  • Unknown
Description of Visual Impairment
Additional Disabilities and/or Medical Conditions
Dietary Restrictions
Birthday
Height
Weight

Emergency Contacts

Contact #1 Name*
Relationship*
Phone*
Contact #2 Name
Relationship
Phone

Waiver

By signing this athlete registration form, the participant affirms having understood all terms and conditions. In consideration of my involvement under the auspices of Northwest Association for Blind Athletes (NWABA) at training and competition sites, I acknowledge and agree to the following: 1.I risk bodily injury, including paralysis, dismemberment and death as well as loss or damage to property; 2. I knowingly and freely assume all such risk; 3. I hereby authorize and give my full consent to NWABA to copyright and/or publish any and all photographs, videotapes and/or film in which I appear while attending any NWABA event. I further agree that Northwest Association for Blind Athletes (NWABA) may transfer, use or cause to be used these photographs, videotapes or films for any exhibitions, public displays, publications, commercials, art and advertising purposes and television programs without limitations or reservations; and 4. I, for myself and on behalf of my heirs, assigns and next of kin, hereby release, hold harmless and promise not to sue the Northwest Association for Blind Athletes (NWABA), their officers, officials, volunteers, agents and/or employees, with respect to any such injury, paralysis, dismemberment, death and/or loss or damage to property except that which is the result of gross negligence and/or wanton misconduct.

For athletes of minority age – (under 18 at time of registration), this is to certify that I, as a parent/guardian of this participant, consent to his/her release of the Northwest Association for Blind Athletes (NWABA) from any and all liabilities incident to his/her involvement in the programs conducted at authorized training and competition sites.

If you are unable to fill out this waiver portion online you may do so at the event or email a signed copy of this form to kpomeroy@nwaba.org. Filling out this form to the best of your ability is still required.

 
 
 
*
  • Submitting this application attests to an agreement to this waiver
Signature
Additional Comments

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