Registration Form

Ten Thousand Lakes Foundation

(TTL)

Youth Program Registration Form

Player's Name*

Last name*

Gender

Male

Female

Date of Birth

School Currently Attending

Grade

Parent/Guardian Information*

Phone Number*

Email Address*

Home Address*

City, State, Zip

Emergency Contact

Relationship to Child*

Emergency Phone Number*

Medical Release and Authorization & Media Release and Authorization*

Agree Medical Release and Authorization: I have read and agree to the Medical Release and Authorization requirements. As Parent and/or Guardian of the named athlete, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor's life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed. Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me. Permission is also granted to Harambee Sports Club and its affiliates including Directors, Coaches, and Team Parents to provide the needed emergency treatment prior to the child's admission to the medical facility. Release authorized on the dates and/or duration of the registered season. This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence. I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, AND SIGN IT FREELY AND VOLUNTARILY.

Agree Media Release and Authorization: I have read and agree to the Media Release and Authorization requirements. As Parent and/or Guardian of the named athlete, I hereby grant Ten Thousand Lakes Foundation and their agents the absolute right and permission to use photographic portraits, pictures, digital images or video of My Child, or in which My Child may be included in whole or part, or reproductions thereof in color or otherwise for any lawful purpose whatsoever, including but not limited to use in any Ten Thousand Lakes Foundation publication or on the TTL FOUNDATION website, without payment or any other consideration. I hereby waive any right that I may have to inspect and/or approve the finished product or the copy that may be used in connection therewith, wherein My Child's likeness appears, or the use to which it may be applied. I hereby release, discharge, and agree to indemnify and hold harmless the TTL FOUNDATION and their agents from all claims, demands, and causes of action that I or My Child have or may have by reason of this authorization or use of My Child's photographic portraits, pictures, digital images or videos, including any liability by virtue of any blurring, distortion, alteration, optical illusion, or use in composite form, whether intentional or otherwise, that may occur or be produced in the taking of said images or videotapes, or in processing tending towards the completion of the finished product, including publication on the internet, in brochures, or any other advertisements or promotional materials. I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, AND SIGN IT FREELY AND VOLUNTARILY. Confirmation I have read and agree to the Confirmation requirements. BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Ten Thousand Lakes Foundation

(TTL)

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