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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
ALL ATHLETES MUST COMPLETE AND RETURN THIS
FORM ALONG WITH REGISTRATION AND YOUR CHECK.

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: ____________
*******************
PERMISSION TO PHOTOGRAPH
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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