Player Information

Player's Primary Care Physician

General Information

Address

Mailing Address (if different from residence)

Emergency Contact Information

Please provide the following demographic data

Statement of Liability

I give authorization for the player named below to participate in the Charleston Miracle League. I believe that participation in the Charleston Miracle League will present no unusual risk for illness or injury to the individual/ player. I know that participation in baseball may result in serious injuries, and protective equipment does not prevent all injuries to players, and I do hereby waive, release, absolve, indemnify, and agree to hold harmless the Charleston Miracle League, the City of Charleston, and their organizers, sponsors, agents, insurers, supervisors, participants, and volunteers from any claim arising out of any injury to this individual whether the result of negligence or for any other cause. I hereby grant the Charleston Miracle League, 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, my family members including my Miracle League player/child. These materials may appear in any form, style, color or medium whatsoever (including, without limitation, photographs, video tapes, films, sound recordings, software, drawings, prints, broadcast, internet and electronic media). I agree that all material containing any identifiable representation of me (including without limitation, all negatives, plates and masters of any photographs, files, prints or tapes) shall be and remain the sole and exclusive property of the Charleston Miracle League. I hereby release and forever discharge the Charleston Miracle League from any and all liability and damages relating to the use of my name, voice, likeness or any other identifiable representation of me. I hereby waive any right I may have to inspect or approve the finished materials or any part or element thereof that incorporate my name, voice, likeness or any other identifiable representation of myself, my family including, my Miracle League player/child. I have fully read and understand this document and that I have had any questions regarding its effect or the meaning of its terms answered to my satisfaction. I certify that I am at least 18 years of age unless this document is also assigned by my parent or legal guardian.