Goalball Registration

For Individuals who are Blind, Visually Impaired and Sighted

(All players must wear a blind-fold)

Register each person attending, even those not playing

Please circle:                

Goalball player: yes   no                                                           Age:  _______ 

Observer:  yes   no

Name of Registrant: _________________________________                            

Parent/Guardian (If applicable):  _____________________________________________

Address:   _________________________________________

               _________________________________________

Phone:     home:  ________________   work:  ________________      cell:  _______________

Email address:  __________________________________________________

In case of emergency contact:  _________________________________________________________________

Medical Issues for those with a Visual Impairment

Are you on physical activity restriction from your eye physician?  _____ no     _____ yes*

* If yes, check with your eye physician for his/her recommendations before playing

Accommodations

_____ No

_____ Yes – Please identify accommodations you require ____________________________

                   ________________________________________________________________

Participant Liability Release

I am aware of the program for which I am registering and I hereby assume responsibility for myself and/or person named ________________________________ to participate in the game of Goalball.  I will not hold the City of Norfolk, Department of Recreation, Parks, and Open Space, Therapeutic Recreation Center and/or its employees or the Chesapeake Bay Chapter of the Blind NFBV responsible in case of an accident or injury as a result of this participation.

Signed_______________________________________                  Date____________________

Photo Release

I give my permission for___________________________________ to be photographed while participating in Goalball.  I understand that the pictures will be used for program publicity.

Signed_______________________________________                  Date____________________

Confidentiality Understanding

I understand the above information given will be kept strictly confidential. 

Signed_______________________________________                  Date____________________

Please Copy or Print, fill out and Send Registration form to:

            Gail Henrich

            800 Bowling Green Trail

            Chesapeake, VA 23320

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