By Completing this form, I acknowledge and agree that I hereby release IHA and Suffolk County or any of their agents for any injury or loss suffered during this event or in connection with this event. Photographs taken at an IHA Sponsored event may be used in publication.

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First and Last Name of Participant: *

First and Last Name of Guardian if Participant is Under 18:

Address: *

Phone Number: *

I hereby release IHA and Suffolk County or any of their agents for any injury or loss suffered during this event or in connection with this event. Photographs taken at an IHA Sponsored event may be used in publication. *

Yes, I agree

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