Contact form for participation and just in case.

Participation Contacts & Model Release

Let us know how to keep in touch with you. And understand, that the participants in our programs help us create learning resources, playbooks, digital badges and other lessons that are shared and used for on-line discussions elsewhere.

First name of player

Last name of player

Gender

Email Address of player

Date of Birth: (Month / Date / Year)

Player's phone number(s):

Address, & City, State, Zip

School and grade:

Health concerns to note:

Feel free to input any issues of concern in terms of the player's health. Allergies? Heart conditions? Asthma? Expected reactions to bee stings? Sleep disorders? If none, just leave this area empty.

Notes on health concerns:

Media and Model Release Form

Permission to publish content on the internet, in books, in advertisements, and elsewhere.

I, being parent/guardian of (the student or adult named on this form), hereby consent that videotapes, photographs and/or audio recordings made of myself and my children within the programs may be used freely by the coach, the associated organizations, sponsors and school districts. Furthermore, I hereby consent that such photographs, and/or tapes from which they are made shall be the property of authors, coaches, partners and sponsors. These include, but are not limited to, Coach Mark Rauterkus, CLOH.org, the nonprofit Bloomfield-Garfield Corporation, Pittsburgh Public Schools, American Water Polo Association, and others.

Answer "YES" or "NO."

Media & Model Release Permitted or Denied:

Guardian Name as Signature and date --OR-- Written objection:

Emergency Contact Insights:

Parent / Guardian Name #1

Parent / Guardian #1 email

Parent / Guardian #1 phone

Parent / Guardian Name #2

Parent / Guardian #2 email

Parent / Guardian #2 phone

Play.CLOH.org

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