Thank you for wanting to register as an athlete. This form helps NWABA provide the safest most successful programs by getting to know all about you. Please know we ask about your health history to best serve you in various physical activity endeavors, answers on this form do not exclude you from participating. This form takes about 15 minutes to complete. Please note if you do not have the latest version of software this form will be finnicky in a few places. Particularly the ReCaptcha at the end of the form. We are working with the company to make their forms more accessible and to remove the Recaptcha at this time.

 

If you would like to have one of our team members fill this out with you over the phone or send you a PDF version, call or text our office at 3604487254. You can also email programsteam@nwaba.org. We look forward to having you with us at programs!

Are you a new athlete to NWABA or re-registering?*
  • New Athlete
  • Re-Registering as an Athlete

Participant Registration Form

Preferred Name (if any)
Pronouns*
If 'Other' was checked, fill in pronoun here
Date of Birth (MM/DD/YYYY)*
Gender**
If other language was checked, please list what is spoken.
Race/Ethnicity (Optional) Check all that apply
Current Grade Level (if applicable)
Highest Education Level (optional)
Participant's Employer, if any (Optional)
Preferred Contact Method?*
Preferred Medium*
Country*
Email*
Confirm Email*
Cell Phone*
Home Phone Number
Sport/Physical Activity Interests: *

Parent/Guardian Information

Required if minor or otherwise has a legal guardian. Please leave blank if it does not apply.

Parent/Guardian First Name
Parent/Guardian Last Name
Parent/Guardian Street Address
City*
State*
Zip Code*
Parent/Guardian Email
Parent/Guardian Phone Number*

Emergency Contacts

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

Emergency Care

Does the participant have the capacity to consent to medical treatment on his or her own behalf?*
  • Yes
  • No

If I, the participant, am unable or my parent/guardian is unable, to consent or make medical decisions in an emergency, I authorize Northwest Association for Blind Athletes to seek medical care on my behalf. Including but not limited to OTC medication, emergency medication, diagnostic procedures, anesthesia, surgical and medical treatment and blood transfusions, by medical providers, hospitals or their authorized designees, as may in their professional judgment be necessary to provide for the medical, surgical or emergency care. 

 

Is NWABA authorized to approve professional medical treatment in an emergency situation?*

Health History

The purpose of requesting health history information is to provide the safest and most successful environment for you while participating in our programs and services. We ask that you take your time and answer all questions honestly.

Associated Conditions (Check all that apply)*
If "Other Condition" was checked, please specify:
If "Cortical Visual Impairment" was checked, please describe:

Allergies & Dietary Restrictions

Please be as specific as possible. Please put N/A if it is not applicable.

List Any Food Allergies (N/A if not apply)*
List Special Dietary Needs (N/A if not apply)*
List any Environmental Allergies (N/A if not apply)*
Allergic to any Insect Bites or Stings (N/A if not apply)*
Allergic to any Medications (N/A if not apply)*
Latex Allergy*

Assistive Devices

Please check all that apply. If you are using an assistive device, please explain when asked below.

Please check all assistive devices that apply:*
If using an assistive device, briefly explain:

Vision

Please identify your visual acuity as best you can. Please provide a description of your visual impairment as best you can.

Vision*
Description of Visual Impairment*
Does participant use a white cane for orientation?*
Does participant have a guide dog? If yes, what is their name?

Health History

Has the participant ever been diagnosed with or experienced any of the following conditions. If yes is answered, we ask for further description below. All questions in this section are required, if you skip a question you will not be able to submit the form.

Arthritis*
  • Yes
  • No
Asthma*
  • Yes
  • No
Broken Bones*
  • Yes
  • No
Cardiomyopathy*
  • Yes
  • No
Concussions*
  • Yes
  • No
Congenital Heart Defect*
  • Yes
  • No
Diabetes*
  • Yes
  • No
Dizziness During or After Exercise*
  • Yes
  • No
Easy Bleeding*
  • Yes
  • No
Endocarditis*
  • Yes
  • No
Enlarged Spleen*
  • Yes
  • No
Headache During or After Exercise*
  • Yes
  • No
Hearing Impairment*
  • Yes
  • No
Heart Attack*
  • Yes
  • No
Heart Murmur*
  • Yes
  • No
Heart Valve Disease*
  • Yes
  • No
Heat Illness*
  • Yes
  • No
Hepatitis*
  • Yes
  • No
High Blood Pressure*
  • Yes
  • No
High Cholesterol*
  • Yes
  • No
Irregular, racing or skipped heart beats*
  • Yes
  • No
Loss of Conciousness*
  • Yes
  • No
Osteoporosis*
  • Yes
  • No
Sickle Cell Disease*
  • Yes
  • No
Sickle Cell Trait*
  • Yes
  • No
Single Kidney*
  • Yes
  • No
Spina Bifida*
  • Yes
  • No
Stroke/TIA (mini stroke)*
  • Yes
  • No
Traumatic Brain Injury*
  • Yes
  • No
Urinary Discomfort*
  • Yes
  • No
If you have been diagnosed or experienced any of the above conditions, please describe:

Health History Continued

Has a doctor ever limited your participation in sports or physical activity?*
If their is risk for retinal detachment, please describe:
If yes to a cortisol insufficiency, please describe:

Emergency Medication Support

All questions in this section are required, if you do not answer a question you will not be able to submit the form. Click not applicable if it does not apply to you.

Does the participant have an epipen?*
  • Yes
  • No
Can participant self-administer their epipen?*
  • Yes
  • No
  • Not Applicable
Does the participant have an inhaler?*
  • Yes
  • No
Can participant self-administer their inhaler?*
  • Yes
  • No
  • Not Applicable
Does the participant have liquid hydrocortisone in case of an adrenal crisis?*
  • Yes
  • No
Can participant self-administer hydrocortisone in case of an adrenal crisis? *
  • Yes
  • No
  • Not Applicable
Other Emergency Medical Medication/Support that is NOT listed?

Neurological Symptoms

All questions in this section are required, if you do not answer a question you will not be able to submit the form. Click not applicable if it does not apply to you.

Difficulty Controlling Bowels or Bladder*
  • Yes
  • No
Numbness or Tingling in Legs, Arms, Hands or Feet*
  • Yes
  • No
Weakness in Legs, Arms, Hands or Feet*
  • Yes
  • No
Burner, Stinger, Pinched Nerve or Pain in the Neck, Back, Shoulders, Arms, Hands, Buttocks, Legs or Feet*
  • Yes
  • No
Head Tilt*
  • Yes
  • No
Spasticity*
  • Yes
  • No
Paralysis*
  • Yes
  • No
If you checked yes to neurological symptoms, are any new or worse in the past 3 years? If yes, which symptoms?

Epilepsy and/or Seizure History

All questions in this section are required, if you do not answer a question you will not be able to submit the form. Click not applicable if it does not apply to you.

Does the participant have epilepsy or any type of seizure disorder?*
  • Yes
  • No
If applicable, list seizure type:
Has participant had a seizure in the past year?*
  • Yes
  • No
  • Not Applicable
If applicable date of last seizure:

Mental Health History

Have you engaged in self-injurious behavior during the past year?*
  • Yes
  • No
Have you presented aggressive behavior during the past year?*
  • Yes
  • No
Have you been diagnosed with anxiety?*
  • Yes
  • No
Have you been diagnosed with depression?*
  • Yes
  • No
Please describe any additional mental health concerns NWABA should know about:
I hereby declare that the information provided is true and correct?*
  • Yes
  • No

Participant Release & Waiver of Liability and Indemnity Agreement

Participant Release & Waiver of Liability and Indemnity Agreement

(“Release and Waiver”)

 

PLEASE READ THIS RELEASE AND WAIVER CAREFULLY AND IN ITS ENTIRETY. THIS RELEASE AND WAIVER AFFECTS YOUR LEGAL RIGHTS AND IS LEGALLY BINDING. BY SIGNING THIS RELEASE AND WAIVER, YOU ARE RELEASING NORTHWEST ASSOCIATION FOR BLIND ATHLETES (“NWABA”) FROM ALL LIABILITY AND FOREVER GIVING UP ANY CLAIMS THEREFOR.   

 

Assumption of Risk

 

I acknowledge and agree that any use of NWABA facilities, services, equipment, and premises (“Facilities”) and any participation in NWABA programs and activities, including virtual programs and activities (“Programs”), comes with inherent risks including, but in no way limited to: (1) moderate and severe personal injury, (2) property damage, (3) disability, (4) death, and (5) sickness or disease.

 

I voluntarily accept and assume full responsibility for these risks as well as any and all other risks of the use of Facilities and participation in Programs. I agree that I have full knowledge of the nature and extent of all such risks and am not relying on all such risks being described in this Release and Waiver.

 

Consultation with Medical Provider

 

YOU SHOULD ALWAYS CONSULT WITH YOUR DOCTOR BEFORE BEGINNING ANY TYPE OF EXERCISE OR PHYSICAL ACTIVITY.

 

I understand NWABA recommends that I consult with a physician before commencing in the participation of any Programs. If I have chosen not to consult a physician prior to participating, I fully accept the risks involved in this decision. At no time has a physician or any other person advised me that I should not participate in physical activity. I affirm that, to the best of my knowledge, I am in good physical condition and do not suffer from any condition that would prevent or limit my participation in the Programs. I acknowledge that if my health changes, it is my responsibility to inform NWABA of any conditions or changes in my health, now and ongoing, which might affect my ability to participate safely and with minimal risk of injury.

 

Waiver, Release, Indemnification, & Covenant Not to Sue

 

In consideration of the use of Facilities and participation in Programs, I, the undersigned, agree that NWABA, along with its affiliates, predecessors, successors, officers, directors, agents, consultants, employees, volunteers, insurers, representatives, and assigns (collectively, “Releasees”) will not be liable for any personal injury, property damage, disability, accident, death, loss, sickness, or disease incurred by myself, my family members, dependents, or guests, including minors, however occurring, including, but not limited to, the negligence of Releasees. I understand that I will be solely responsible for any loss or damage, including personal injury, property damage, disability, death, sickness, or disease sustained from the use of Facilities and participation in Programs.

 

I further agree, on behalf of myself and any and all legal successors, assigns, and proxies, to release and HEREBY DO RELEASE, WAIVE, AND COVENANT NOT TO SUE Releasees from any causes of action, claims, suits, liabilities, or demands of any nature whatsoever including, but in no way limited to, claims of negligence, which I and any and all legal successors and proxies may have, now or in the future, against Releasees on account of personal injury, property damage, disability, death, sickness, diseases, or accidents of any kind, arising out of or in any way related to the use of Facilities or participation in Programs, whether that participation is supervised or unsupervised, and however the injury or damage occurs, including, but not limited to, the negligence of Releasees. This Release and Waiver does not extend to claims for gross negligence, intentional or reckless conduct, or any other liabilities that applicable law does not permit to be excluded by this Release and Waiver.  

 

I also agree not to sue or make a claim against the Releasees for personal injury, property damage, disability, death, sickness, diseases, or accidents of any kind, arising out of or in any way related to the use of Facilities or participation in Programs. 

 

In further consideration of the use of Facilities and participation in Programs, I agree to INDEMNIFY AND HOLD HARMLESS Releasees from any and all causes of action, claims, demands, losses, suits, judgments, settlements, awards, interest, penalties, liabilities, or costs of any nature whatsoever, including claims of negligence, arising out of or in any way related to the use of Facilities and participation in Programs by myself, my family members, dependents, or guests, including any minors. In accordance with these promises, I will reimburse the Releasees for any damages, reasonable settlements, and defense costs, including attorneys’ fees, that they incur because of any such claims made against them. I agree that in the event of my death or disability, the terms of this Release and Waiver, including the indemnification obligations, will be binding on my estate, and my personal representative, executor, administrator, or guardian will be obligated to respect and enforce them. 

 

Use of My Likeness

 

I hereby grant NWABA and its assigns permission to use my likeness in a photograph, video, or other digital media (“photo”) in any and all of its publications, including web-based publications, without payment or other consideration. I further license NWABA and its assigns the right to use photos or likenesses of me for the purposes described in this authorization.

 

I understand and agree that all photos will become the property of NWABA and will not be returned. I hereby irrevocably authorize NWABA to edit, alter, copy, exhibit, publish, or distribute these photos for any lawful purpose. In addition, I waive any right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising out of or related to the use of the photo. This authorization specifically includes the right to take and record photographs or likenesses of me, and the right to use my name and any such photographs or likeness for the purposes described in this authorization. 

 

Severability and Termination

 

I expressly agree that this Release and Waiver is intended to be as broad and inclusive as permitted by the law in the state the Programs take place. Any portion of this Release and Waiver deemed unlawful or unenforceable is severable and shall be stricken without any effect on the enforceability of the remaining portions of this Release and Waiver, or this Release and Waiver as a whole, to the full extent authorized by law. 

 

This Release and Waiver shall remain in full force and effect unless and until terminated by written notice delivered to NWABA. Any termination of this Release and Waiver shall apply prospectively only and shall not serve to invalidate the terms of this Release and Waiver as to any claim, activity, or event occurring prior to the date of such termination.

 

I certify that I have reviewed all of the above terms of this Release AND WAIVER, and, by signing below, I hereby accept and agree to the terms of this Release AND WAIVER in their entirety. I UNDERSTAND THIS IS A CONTRACT THAT AFFECTS MY LEGAL RIGHTS AND I SIGN IT OF MY OWN FREE WILL.    


For participants of minority age (under 18 at time of registration), by signing this Release AND WAIVER, you give up your right and the named minor’s right to bring any claim for damages or cause of action to recover compensation or obtain any other remedy or relief for any personal injury or property damage, however caused, arising out of the named minor’s participation in Northwest Association for Blind Athletes Programs or use of Facilities, now or any time in the future.

 
Certify that I have reviewed all of the above terms of this Release and Waiver*

Participant Signature

Participant Signature*
Today's Date (mm/dd/yyyy)*

For Minors: Parent/Guardian Signature

Parent/Guardian Signature
Additional Comments

Security

Share This Form

Powered by eTapestry