BlazeSports Athlete Annual Membership Registration

Membership Level: First Name: Middle/Initial: Last Name: Home Address: Address Line 2 City: State/Province: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico U.S. Minor Outlying Islands Virgin Islands Armed Forces Americas Armed Forces Europe, the Middle East, an Armed Forces Pacific Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Territory Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory Zip: - Zip Suffix Participant Date of Birth Email: Home Phone: Gender: Female Male T-Shirt Size Adult 2XL Adult 3XL Adult 4XL Adult L Adult M Adult S Adult XL Youth L Youth M Youth S Youth XL Primary Disability Amputation - Lower Extremity Amputation - Upper Extremity Arthrogryposis Brain Injury Caudal regression syndrome Cerebral Palsy Dwarfism Epilepsy/Seizures Hydrocephalus Ichthyosis McCune Albright Syndrome Muscular Dystrophy Muscular Scoliosis Osteogenesis Imperfecta Polyostotic Fibrous Dysplasia Spina Bifida Spinal Cord Injury Stroke TBI Usher Syndrome (Hearing, VI) Visually Impaired/Blind Other Disability - Description Secondary Disablity Amputation - Lower Extremity Amputation - Upper Extremity Arthrogryposis Brain Injury Caudal Regression Syndrome Cerebral Palsy Dwarfism Epilepsy/Seizures Hydrocephalus Ichthyosis Limb Dysgenesis McCune Albright Syndrome Muscular Dystrophy Muscular Scoliosis Osteogenesis Imperfecta Polyostotic Fibrous Dysplasia Spina Bifida Spinal Cord Injury Stroke TBI Usher Syndrome (Hearing, VI) Visually Impaired/Blind Other Assistive Device #1 Braces Cochlear Implant Crutches/Canes Leg Braces Manual Wheelchair Orthotics Wheelchair Prosthetics Quad Canes Walker Other N/A Assistive Device #2 Braces Cochlear Implant Crutches/Canes Leg Braces Manual Wheelchair Orthotics Power Wheelchair Prosthetics Quad Canes Walker Assistive Device #3 Manual Wheelchair Power Wheelchair Prosthetics Orthotics Crutches/Canes Walker Braces Quad Canes Cochlear Implant Allergies Allergies - Description Emergency Contact First Name Emergency Contact Last Name Emergency Contact Relationship to Participant Emergency Contact Phone # I have read the BlazeSports America Release of Liability and Publicity Waiver and fully understand its terms. I understand that my answer of "yes" below represents my signing it freely and voluntarily without inducement. Yes Confirm Membership Type Youth Veteran