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ROC The Barriers with Miracle By The Bay Event 2021  Registration Form
This event and focuses on fostering and building relationships between the special-needs and general population’s while showcasing all the services and providers available to the special needs community within our area

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Participants Name:
Parent/Guardian Name:
Age Group:
Organization that referred you:
Number of Activity Participants
Number of People Attending:
Liability and Release Statement
To the best of my knowledge, I am in good physical condition and fully able to participate in the R.O.C. The Barriers Field Day. I am fully aware of the risks and hazards connected with the participation in this program, including physical injury and damage to property and elect to voluntarily participate in said event. I VOLUNTARILY ASSUME FULL RESPONSIBILITY FOR ANY RISKS OR LOSS, PROPERTYDAMAGE, OR PERSONAL INJURY that may be sustained by me as a result of participation in this program and hereby waive all claims against R.O.C. Park and The City of Madeira Beach, of any injury that I may suffer from my participation. I grant full permission to organizers to use my photograph or appropriate quotations from me in legitimate accounts and promotions of this program. By clicking yes your knowledge this statement
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Full Name
Street Address
Zip Code
Do you grant permission to Miracle By The Bay and it’s community partners and all parties involved The rights to your image in video or still photo or likeness and sound of your voice as recorded on audio or video tape? Do you understand that your image may be edited copied or  published or distributed on all social media platforms and wave  any and all rights to inspect or approve the finished product where in your likeness appears additionally do you wave the right to royalties or other compensation arising or related to the use of your image or recording
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If you would like more information on this event please contact Miracle by the bay director of operations Matthew Walker at 727-412-4292 or director of community events and programs Veronica Sierra at 424-283-2723 you can also contact Roc Park assistant executive director Paige Karns via email at
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