Walking with Kpeasey in Utah, Inc. 

Application for Sponsorship

 

Please complete the form below

Prospective Athlete's Full Name *
Prospective Athlete's Full Name
Birthdate *
Birthdate
Home Address:
Home Address:
Who is completing this application for an Athlete Sponsorship from Walking with Kpeasey in Utah? *
How did you hear about Walking with Kpeasey in Utah Athlete Sponsorship Program?
Prospecive athlete's medical information
Please complete the following section so that Walking with Kpeasey in Utah can better understand the prospective Athlete's need so that we may work better to meet those needs.
(please list each disability with age of diagnosis, as well as if this is a current or past condition)
Please check which, if any, of the following does the prospective Athlete uses or has previously used:
Contact lenses / glasses
Manual wheelchair
Electric wheelchair
Walker / leg braces
Oxygen / nebuilizers
Catheters
Feeding equiptment
MEDICATION - DOSE - FREQUENCY - REASON
ALLERGIC TO - REACTION:
How often does the prospective Athlete currently engage in any exercise or athletic activities?
Parent/legal Guardian of Athlete
Date:
Date:
Parent/legal Guardian of Athlete
Date
Date
Liability Release and Information Authorization
The undersigned (collectively, the “Participants”) have voluntarily requested that Walking with Kpeasey in Utah, Inc., a Utah nonprofit corporation, and its directors, officers, employees, volunteers, agents, advisors, legal representatives, successors or assigns (collectively, “WWKPU”) sponsor the “Athlete” as a WWKPU Athlete. Participants acknowledge and are aware there are risks inherent in participating in athletic events. WWKPU is not the sponsor or organizer of the athletic event described above and has no control over the conditions or other factors involved in the event. WWKPU cannot be held responsible for any injuries or other damage sustained during the Activity. Participants certify that the Athlete is of a physical condition allowing them to safely participate in the Activity and have not been otherwise informed by any physician or know of any restrictions imposed on them by any physician that would in any way prevent them from safely participating in the Activity. Furthermore, Participants acknowledge that the sponsorship provided by WWKPU is extended to Participants expressly in reliance upon the representations made by Participants in their Application for Sponsorship. Liability Release Participants understand that involvement in the Activity may entail risk of injury or harm to Participants and agree that this risk is fully assumed by Participants. In consideration for the above described sponsorship Activity, the undersigned Participants, and their respective heirs, distributees, guardians, legal representatives and assigns agree that they will not make a claim against, sue, attach the property of, or prosecute WWKPU for any and all injury or damage resulting from or in connection with the Activity or the use of any equipment provided in connection with the Activity. In addition, Participants hereby release, forever discharge, and hold WWKPU harmless from any and all actions, claims or demands that Participants and their respective heirs, distributees, guardians, legal representatives, or assigns now have or hereafter may have for any and all injury or damage resulting from the Activity or the use of any equipment provided in connection with the Activity. This includes, but is not limited to, claims involving economic loss, illness or medical condition, accidental injury or death. Participants further agree that in the event any clause or provision of this Liability Release and Information Authorization shall be held to be invalid by any court of competent jurisdiction, the invalidity of such clause or provision shall not otherwise affect the remaining provisions of this Liability Release and Information Authorization, which shall continue to be enforceable. Responsibility for Medical Care The parent or legal guardian of the Athlete understands and agrees they are required to be present at all WWKPU events the Athlete attends, particularly while the Activity is being fulfilled, and such parent or guardian will be solely responsible for obtaining medical attention for the Athlete if the need arises. Publicity Authorization Participants understand and agree that fulfillment of the Activity may result in publicity, whether or not WWKPU actively takes steps to publicize the Athlete or the Activity. However, to the extent WWKPU has control over the matter, the Athlete’s parents or guardians are asked to choose what information is allowed to be publicized by WWKPU regarding the Athlete and/or the Activity for purposes of promotion, publication, social media advertising, or any other similar purpose, now or at any time in the future, and without the need to notify or seek further approval before doing so. Notwithstanding the foregoing, Participants hereby provide WWKPU with permission to use the Athlete’s first name, disability, and one recent photo of the Athlete in order to fulfill the Activity for the Athlete. Additionally, by submitting this publicity release, the Athlete’s parents/guardians understand and accept that information regarding the Activity and Athlete will necessarily be discussed with and disclosed to those involved in the preparation and fulfillment of the Activity and that even if WWKPU does not actively publicize information they are not given authorization to publicize, the general public and media may obtain that information during the Athlete’s participation in the Activity. Participants acknowledge reading and understanding this Liability Release and Information Authorization. For the Athlete and any other Participant, the signature of their parent or guardian is on behalf of the parent/guardian and on behalf of the Athlete or other minor. Participants agree that this Liability Release and Information Authorization full and accurately express their understanding and has not been modified orally or in writing. I, the undersigned, hereby certify that I am the parent or legal guardian of the prospective Athlete, and as such and on behalf of myself and the prospective Athlete, I agree to the terms of this Liability Release and Information Authorization.