EMERGENCY INFORMATION
Health Concerns/Allergies
Information we should have available in the event of an emergency, such as current prescription medications. You may also
use this space to indicate over-the-counter medications you do not wish to be dispensed to your child.
_____________________________________________________________________________________________________________________________________________________________
Emergency Contact Phone: ___________________________________________________
The phone number for the individual we should contact in the event of an emergency if we can’t reach you at the numbers above.
Please include area code and extensions (if necessary).
PARTICIPANT INFORMATION
____________________________________________________________________________________________________________________________________________________________
Name: First Last
Gender: Female Male Other
____________________________________________________________________________________________________________________________________________________________
Birth Date (mm/dd/yyyy) Current Grade
PARTICIPANT REGISTRATION
TEAM NUMBER: _________________________ (Team Manager to ll this out.)
You may submit this information online at www.RegisterYourTeam.org/
participant using the Team Number above. If you are not able to submit
online, please ll out this form and return it the Team Manager.
PARENT/GUARDIAN INFORMATION
______________________________________________________________________________________________________________________________________________________________
Name: First Last
______________________________________________________________________________________________________________________________________________________________
Email Address
______________________________________________________________________________________________________________________________________________________________
Address City, State Zip
______________________________________________________________________________________________________________________________________________________________
Phone (Primary) Phone (Alternate)
I acknowledge that I am a parent or legal guardian of the participant described on this form, or the participant (if the participant is over
18) and that I agree to the Participation Agreement above.
_________________________________________________________________________________________________________________________________________________________
Signature of Parent/Guardian Date
/ /
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PARTICIPATION AGREEMENT
Liability Release / Disclaimer
I understand that the participant listed on this form will be attending a Destination Imagination Tournament.
By participation in an event by an Afliate or Region, or other gathering related to the Destination Imagination program, the participant or
participants' parents or participating guardian understands and hereby voluntarily agrees to release, waive, forever discharge, hold harm-
less, defend and indemnify Destination Imagination Inc., and their agents, ofcers, boards, volunteers, and employees from any and all li-
ability and all claims, actions, or losses for bodily injury, property damage, wrongful death, loss of services, or otherwise which may arise out
of the participant's participation in activities related to the Destination Imagination event, including travel to and from the event.
Media Release
We (I) hereby grant permission for Destination Imagination, Inc. and their licensees to publish images of activities and of this participant for
the purpose of promoting Destination Imagination®. We (I) grant this permission freely without reservation.
If the participant is under the age of 18:
Furthermore, we (I) are (am) the parent(s) or legal guardians(s) of this participant and hereby grant permission for him/her/them to partici-
pate fully in the tournament and hereby give permission to take him/her to a doctor or hospital and authorize medical treatment including,
but not limited to, emergency surgery, tests, medications or x-rays. We (I) will assume all responsibility for all medical bills, if any. We (I)
understand that if medical treatment is required we (I) will be contacted as soon as possible. Should it be necessary for my child to be sent
home for medical reasons, disciplinary reasons, or otherwise, we (I) will hereby assume all costs.
Pin Creation Guidelines
In the event that we (I) design or create any pins, we (I) agree to adhere to all guidelines set forth by Destination Imagination, Inc. and my
(our) Afliate regarding pin creation. These include, for example, avoiding copyright infringement and using licensed vendors. A summary of
these requirements can be found at www.destinationimagination.org/pin-vendors.
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