Let’s play goalball!
Junior Blind invites all students grades 2-12
living in the Southern California area to participate
in our Goalball Program.
Join today!
No experience necessary. All skill levels welcome.
Join the team, get fit and make friends! Goalball is a team sport specially designed for athletes who are
blind or visually impaired. The game is played by two teams of three players each, on a gymnasium court
divided into two halves by a center line. The purpose of the game is for each team to throw a ball across the
opponent’s goal line while the opponent tries to stop it. The ball has bells inside that can be heard as the
ball moves by the blindfolded players. Junior Blind abides by the rules established by the International Blind
Sports Federation.
ATHLETE INFORMATION
Last Name
First Name
Address
County
CA
Street Address
City
Phone
State
Zip
E-Mail
School Name
Date of Birth
Current Grade
1.
Male
Female
2.
Totally Blind
Partially Sighted (High Vision)
Ethnicity
Partially Sighted (Low Vision)
FALL 2015 PRACTICE DATES & TIMES




September 12th, 19th
October 3rd, 10th, 17th, 31st
November 7th, 14th, 21st
December 5th
TIME: 9:00 a.m. to 11:00 a.m.
PLACE: Junior Blind Gymnasium, 5300 Angeles Vista Boulevard, Los Angeles, CA 90043
BACK SIDE MUST BE COMPLETED
THIS SIDE MUST BE COMPLETED
ATHLETE MEDICAL AUTHORIZATION, MEDIA & LIABILITY RELEASE
This is a legally binding liability release, waiver, discharge and covenants not to sue Junior Blind and any of their
employees or agents representing or related to the Junior Blind Goalball Program. This release is for any and all liability
for personal injuries (including death) and property losses or damage occasioned by, or in connection with any activity
or accommodations for this event. The undersigned, and all family members and guests attending the event, further
agree to abide by all rules and regulations as set forth by Junior Blind and/or its affiliate groups and vendors throughout
the program. I represent that the registered athlete is physically fit and properly conditioned to participate in the
activities associated with this program. As a Parent/Legal Guardian, I give my permission for my child to participate in
the Goalball Program and release Junior Blind and/or their employees and/or representatives from liability related to
this program.
Full permission is hereby given to Junior Blind to take pictures, motion pictures, video tape or live television pictures, or
otherwise record, preserve, reproduce or depict the activities, voice and likeness of the above-mentioned athlete and
any family members or guests of said participant, and to use any and all of the same publication including television
release and theater viewing, and website or social media site without compensation to said person or to the
undersigned on his/her behalf, or individuality.
In the event the registered athlete becomes ill or sustains an injury while participating in the Goalball Program, the
athlete, or the undersigned parent or legal guardian (if under 18), gives permission to those immediately in charge to
administer or provide or to supervise the administration or provision of first aid, if such first aid appears necessary or
otherwise advisable in the opinion of those immediately in charge. Should it be impossible or unreasonably difficult to
reach the doctor named below within a reasonable amount of time after the event causing the necessity of such
communication, or to receive instructions from the undersigned parent or guardian for the athlete’s physical care,
consent is hereby given to any licensed physician and/or surgeon to treat such athlete, administer drugs and/or
medication, or perform such surgical procedures as the emergency may in the opinion of such physician or surgeon
reasonably require.
Junior Blind is hereby expressly absolved from any and all liability for further injury or other damage or harm caused by
physician or surgeon acting pursuant to the terms of this release.
X
Signature of Parent or Guardian (if under 18)
Date
Name of Emergency Contact (Other than Parent or
Guardian)
Phone Number of Emergency Contact
Family Doctor
Phone Number
Insurance Carrier
Policy Number
 Is the athlete taking any medication? If so, specify:
 Does the athlete have any allergies? If so, specify:
 Name of person authorized to take athlete home after program:
To register, please complete this form (print clearly in blue/black ink) and return it to:
Josh Lucas • Junior Blind • 5300 Angeles Vista Boulevard • Los Angeles, CA 90043 • Fax: (323) 296-0424
For more information, please contact Josh Lucas at (323) 295 4555 x 272 or [email protected].