ATG Registration

REGISTRATION

December 5, 2020 8am - 5:30pm MST WEBSITE: www.TransplantAZ.org email: info@transplantteamaz.org Phone: 602-277-2661
PARTICIPANT'S NAME:
- 2020 Registration Form submited DECEMBER 4, 2020.
- Donation Suggested
- Consent and release Form (signed by parent if participant is a minor)
To participate, you need an internet connection and a computer or device.

Some of the workshops may encourage your active participation, so you may want to plan for a stand for your device, a camera and microphone to communicate with the Coach or Presenter. For example, if you are in a tennis workshop, the Coach may ask to see your swing or your stance.

After we receive your completed registration and fee, you will receive an email wtih the Zoom codes. You will received your shirt via mail in November. If you want to join Ability360, you will receive a separate email with details on how to join.
Participant's Name *

First Name Last Name
Gender *

Female Male
Over 18 years old on 12/5/2020 *

Yes No
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Home Phone

Area Code Phone Number
Cell Phone *

Area Code Phone Number
E-mail *
email to send Zoom information
Name of Spouse/ Caregiver/ Significant Other
What team(s) do you represent?
ie Team Liberty, Team USA, Team St. Joseph's
Would you like to be added to the TCA email list?

Yes No
Transplant Related Information
Transplant Status

Transplant Received Living Donor LVAD or other assist device On the Waitlist
Where were you Transplanted?
Type of Organ(s), Cornea, Bone Marrow or Tissue Transplanted or Donated?
Date of Transplant or Donation?

Month Day Year
Date
Sports

Please select one from each time block. Descriptions of blocks online at www.TransplantTeamAZ.org/ArizonaGames. Use the link in your confirmation email to change your sport selection until 11:59pm Sunday November 29, 2020. ****Times are for Arizona, MST****
7:00-7:50 am

Open House
8:00-9:15 am

Track & Field Golf
9:30-10:45 am

Basketball Spanish-language Intro to Games
11:00-12:15 pm

Cornhole Swimming Tennis
12:30-1:45 pm

Pickleball Youth Olympiad
Mail the "Transplant Games in a Box"?

Yes- By selecting "YES" I understand there may be items in the box that may cause allergies and I accept all responsibility. No Yes - but mail to this address:
Alternate Address
2:00-3:15 pm

Badminton Bowling
3:15 - 4:30 pm

Cycling Trivia
4:30 pm

Panel Discussion and Wrap-up
PARTICIPATION RELEASE AND ASSUMPTION OF RISK
I hereby apply to participate in the 2020 Arizona Transplant Games from the safety of my home and by typing my name at the end of this application, I represent that I am qualified to participate in the Games and have read, understood and agree to all of the RULES and GUIDELINES of Transplant Team Arizona (hereafter “TTA”) governing the 2020 Arizona Transplant Games. I also understand and agree that my REGISTRATION FEES paid are NOT REFUNDABLE under any circumstances. In consideration of being allowed to participate, in any way in TTA’s sports program, related events and activities, I acknowledge and willingly agree to comply with the stated and customary terms and conditions for participation. If however, I observe any unusual significant hazard during my presence or participation, I will remove myself from the participation and immediately bring such to the attention of the nearest TTA official.

I further understand that the risk of injury from the activities involved in this program is significant, including the potential for permanent paralysis and death, and while particular rules, equipment and personal discipline may reduce this risk, the risk of serious injury does exist and also understand that I will not be covered by any insurance provided by TTA or Transplant Community Alliance and hereby represent and warrant that I either have my own major Medical Insurance Policy or, if not, will be solely responsible to pay any expenses of any injury to myself while participating in the 2020 Arizona Transplant Games.

I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES or others, and assume full responsibility for my participation and for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE AND HOLD HARMLESS TTA and Transplant Community Alliance, their officers, board members, officials, agents and/or employees, other participants, sponsoring agencies, sponsors, advertisers, and, if applicable, owners and lessors of the premises used to conduct the event (“Releasees”) WITH RESPECT TO ANY AND ALL INJURY, DISABILITY or DEATH, suffered by me or loss or damage to person or property caused by me, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE against any and all rights and claims which I may have or which may arise in conjunction with my participation in or travel to and from practices, track meets, road races or other activities sanctioned, sponsored and/or conducted by TTA or the Transplant Community Alliance in conducting the 2020 Arizona Transplant Games.

I HAVE READ THIS APPLICATION, RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY TYPING MY NAME BELOW, AND DO SO FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.
PHOTO RELEASE FORM

I hereby consent to the use of my likeness or my minor's likeness in interviews, the use of quotes, and the taking of photographs, movies or video tapes by TRANSPLANT TEAM AZ and TRANSPLANT COMMUNITY ALLIANCE. I also grant to the right to edit, use, and reuse said products for non-profit purposes including use in print, on the internet, and all other forms of media. I also hereby release TRANSPLANT TEAM AZ and TRANSPLANT COMMUNITY ALLIANCE and its agents and employees from all claims, demands, and liabilities whatsoever in connection with the above.
Choose one: *

I CONSENT to photo release I DO NOT CONSENT to photo release
I AGREE that the information entered on this form is true and accurace. I UNDERSTAND THAT ALL FEES ARE NON-REFUNDABLE.

I also hereby certify that I, or the minor child(ren) listed above, will take part in regular physical activity of at least three times per week for a minimum of 20 minutes per exercise period in preparation for this event.
I understand and agree with the above statement. *

Yes No
Competitors name for consent *
FOR PARTICIPANTS OF MINORITY AGE (UNDER AGE 18 AT THE TIME OF REGISTRATION)
This is to certify that I, as parent/guardian with legal responsibility for this participant, do consent and agree to his/her release as provided above of all the Releasees, and, for myself, my heirs, assigns, and next of kin, I release and agree to indemnify and hold harmless the Releasees from any and all liabilities incident to my minor child’s involvement or participation in these programs as provided above, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES, to the fullest extent permitted by law.
Consent of Parent or guardian of competitor:

First Name Last Name
Today's Date *

Month Day Year
Date
Should be Empty:

REGISTRATION

Transplant Related Information

Sports

PARTICIPATION RELEASE AND ASSUMPTION OF RISK

PHOTO RELEASE FORM