Personal Information
Street, City, State, Zip
Liability and Release Statement

To the best of my knowledge, I am in good physical condition and fully able to participate in the Adapted Sports Festival. I am fully aware of the risks and hazards connected with the participation in this program, including physical injury and damage to property and elect to voluntarily participate in said event. I VOLUNTARILY ASSUME FULL RESPONSIBILITY FOR ANY RISKS OR LOSS, PROPERTY DAMAGE, OR PERSONAL INJURY that may be sustained by me as a result of participation in this program and hereby waive all claims against University of Maryland Rehabilitation & Orthopaedic Institute, of any injury that I may suffer from my participation. I grant full permission to organizers to use my photograph or appropriate quotations from me in legitimate accounts and promotions of this program.

Type Name
(if applicant is under 18 years of age)
Photography & Audio/Video Recording Consent

I give the University of Maryland Medical System and the University of Maryland Rehabilitation & Orthopaedic Institute permission to share my name with members of the news media, and those working for us on publications, news releases, educational projects or web site stories.

I am aware that I may place restrictions on what material UM Rehab can use or where it can be used by stating those restrictions below. Once the information is released, UM Rehab does not have control over how it is further used or shared.

This authorization is valid in perpetuity from the date it is signed unless withdrawn by notifying us in writing at the address below.  If authorization is withdrawn, UM Rehab will discontinue use of the image/information but UM Rehab cannot rescind prior disclosures it has already made. UM Rehab has no control over the public’s usage of information once it is released, and is not responsible for third party use of information/images as a result of prior disclosures.

I am aware I may withdraw my permission by contacting UM Rehab in writing at the following address:

Communications Department
2200 Kernan Drive
Baltimore, Maryland 21207

(if applicant is under 18 years of age)
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