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The Burke Rehabilitation Hospital - Wheelchair Games App 2006 (Page 5)

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The Burke Rehabilitation Hospital - Wheelchair Games App 2006
2006 Burke Wheelchair Games
Sponsored by The Burke Rehabilitation Hospital
Co-Sponsored by the Tri-State Wheelchair Athletic Association
and The National Disabled Sports Alliance
Saturday, September 30, 2006

RELEASE OF LIABILITY (required for athletes)

In consideration of acceptance of this entry form, I/we hereby for ourselves, our
heirs, administrators and assigns, waive and release any and all claims against
Burke Rehabilitation Hospital, Wheelchair Sports USA, Tri-State Wheelchair
Athletic Association, and National Disabled Sports Alliance, for all injuries and/or
expenses incurred by me/us at the Burke Wheelchair Games to be held on
September 30, 2006.

Signature of Competitor: ______________________ Date: ____________

Legal Guardian: _______________________ Date: ____________
I hereby authorize the Games Committee to take and use photographs of me during
the meet for publicity purposes and/or for use in future programs.

Signature of Competitor: _____________________ Date: ____________

Legal Guardian: _______________________Date: ____________
**Return this form with your registration**
Questions? Call (914) 597-2850 and leave a message. We will return your call as soon as
possible. We reserve the right to cancel any event due to lack of participation.
Wheelchair Games - 2006
The Burke Rehabilitation Hospital
785 Mamaroneck Avenue
White Plains, New York 10605

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