Sports Experience Intake Form

Participants understand that involvement in the experience may entail risk of injury or harm to the participants and agree that this risk is fully assumed by the participants. In addition, and in consideration of Mitchell Thorp Foundation considering the Experience and, if it so determines,
granting the Experience, the Participants hereby release and agree to hold Mitchell Thorp Foundation harmless for, from and against any and all liability, damages, and claims (“Claims”) of any kind, known and unknown, which may be connected with, result from, or arise out of the consideration, preparation, fulfillment, or participation in the Experience. This includes, but is not limited to, claims involving economic loss, illness or medical condition, accidental injury, or death.

Choose One *

OPTION 1 [Publicity O.K.]: Participants authorize Mitchell Thorp Foundation to publicize the Experience and to use Participants’ names, likenesses and other information about Participants and the Experience (including Child’s medical condition), whether embodied in photographs, videotapes, recordings or any other format (collectively, “Information”), for purposes of promotion, publication, commercial advertising, or any other purpose whatsoever, now or at any time in the future. Participants understand and agree that Mitchell Thorp Foundation may use any such Information: (1) in all manner and media whatsoever, whether now known or hereafter invented, including electronic and print media and the Internet; (2) with or without Participants’ names; (3) without the payment of royalties or other compensation to anyone; and (4) without the need to notify them or to seek further approval before doing so. OPTION 2 [Prefer no publicity]: Participants request that information about their involvement in the Experience not be actively publicized by Mitchell Thorp Foundation to the electronic or print news media, posted on the Internet, or used in Mitchell Thorp Foundation “collateral” such as newsletters, brochures, annual reports, etc. However, each Participant understands and agrees: (1) that information regarding the Experience and Participants will necessarily be discussed with and disclosed to those involved in the process; (2) that Mitchell Thorp Foundation may publicly describe and promote the Experience generally, without specifically identifying Participants; and (3) that even if Mitchell Thorp Foundation does not actively publicize the Experience, the general public and media may obtain information concerning Participants’ involvement in the Experience from other sources.

Participants acknowledge reading and understanding this release and authorization. For the child and any minor participants, the signature of their parent or guardian is on behalf of the parent/guardian and on behalf of the minor. Participants agree that this release and authorization fully and accurately expresses their understanding and has not been modified orally or in writing.

I understand and agree.

That no promises or assurances whatsoever have been made to me by any representative of Mitchell Thorp Foundation regarding the requested experience;
That the granting of any experience and the participation of any person in the experience are contingent upon approval by Mitchell Thorp Foundation and the child’s physician, as well as full compliance with all conditions, qualifications, and restrictions designated by Mitchell Thorp Foundation;
That all individuals with parental or custodial rights for the child must approve the experience before it is granted and must sign all necessary documents; and that the receipt of an experience may impact the eligibility for public assistance and/or benefits.

I promise that the information provided by me is true and complete to the best of my knowledge.