Fw: Paralympic Cycling Day is June 25

[Guest guest]

FYI

Ellen

Ellen Garber Bronfeld

egskb@...

Paralympic Cycling Day is June 25

Please join me on Saturday, June 25 at Northerly Island for a fun and FREE

introduction to Paralympic cycling, hosted by the Chicago Park District. The

attached file has details and forms for completion.

Note that there are two sessions and registration is required so we have

appropriate equipment. Tandem bikes, handcycles and recumbent bikes will be

available along with experts to fit them and instruct in their safe use.

I hope to see you there!

Pamela J. Redding

Director of Paralympic and Disability Sport

World Sport Chicago

200 East Randolph Street, 20th Floor

Chicago, IL 60601

(312) 861-4848 office

(847) 323-4049 mobile

(312) 861-4801 fax

Northerly Island Visitor Center

1400 S. Lynn White Drive

Chicago, IL 60605

Please register for a session:

Session 1 - 9am to 11am

Session 2 - 12pm to 2pm

Free event, no experience

required!

Skilled instructors will be

present to match cyclists with

equipment for riding along the

lakefront

Handcycles, Tandems and

Adaptive Bikes will be

available

Registration is Due by:

Friday, June 10, 2011

All participants must

complete a Chicago Park

District participant form

and World Sport Chicago

Waiver.

To register, contact:

Pam Redding

312-861-4848 (office)

predding@...

Tun

312-742-4913 (office)

312-742-5393 (fax)

.Tun@...

Open to participants with

primary physical and

visual disabilities

Saturday, June 25th, 2011

PARALYMPIC CYCLING DAY

Participant Information Park Name

NOTE: This form must be filled out in its entirety without modification or

participation will be denied.

Participant Information

Registered Receipt Numbers/Activity Codes/Activity Names

Participant Name(s)

Street Address, Apt/Unit Gender Birth Date Phone Number

City, State, Zip Code Email Address (optional) of Participant or Parent/Legal

Guardian

School (if student) Grade (if student) Age T-shirt size*

*Not all programs provide T-shirts. Choose from youth sizes 2T-4T, 2-3, 4-5,

6-8, 10-12, 14-16, or adult sizes S, M, L, XL

Emergency Information

Primary contact

Name (Parent/Legal Guardian if Participant is a child) Participant's

Physician/Hospital Name Phone Number

Day Phone Evening Phone Relationship to Participant Insurance Company Policy

Number

Secondary Contact

Name

Day Phone Evening Phone Relationship to Participant

Participant Special Needs, such as Allergies/Medications

Signature (Parent/Legal Guardian if Participant is a child) Date

Agreement to Participate

Signature (Parent/Legal Guardian if Participant is a child) Date

Parent/Legal Guardian Agreements

The following agreements apply to all Park District programs.

My child(ren) may walk home unescorted at time of dismissal.

o Yes o No

Name Relationship to Child

Name Relationship to Child

Name Relationship to Child

Is anyone prohibited from picking up your child(ren)?

o Yes o No

If yes, who?

Signature Parent/Legal Guardian Date

Name Relationship to Child

I understand my child must be picked up daily by the assigned

dismissal time or a $5.00 per 30 minutes late fee will be assessed.

Warning: Repeated late pick-up (more than twice) will result in the

expulsion of your child from the program. If your child has not been

picked up by 8:00 p.m., the park staff will contact the Police

Department.

Who is permitted to pick up your child(ren)? Your child(ren) will only be

released to

listed person(s). Anyone picking up a child must present a picture I.D.

In the event of a medical emergency, I hereby authorize and give

my consent to the Chicago Park District and its employees,

coaches and/or volunteers to secure from any accredited hospital,

clinic, and/or physician any treatment deemed necessary for my or

my child's immediate care. I agree that I shall remain responsible

for any and all expenses incurred for such emergency medical care

and treatment.

I hereby give permission for my child to participate in park activities,

including swimming and field trips. I fully assume all responsibility

for injuries she/he or I may receive or articles lost while participating

in these activities or while in travel to or from said activities and field

trips, and hereby release the Chicago Park District and its

employees from liability for any injury I or my child(ren) may

sustain.

I have received, read and understand the " Program Information

Sheets for Parents " (for Summer Camp and PARK Kids only) and

agree to abide by the policies stated therein. I understand that this

form will be due the first day of class or my child will not be

enrolled. I have read and agreed to all the information contained in

the above Parental Agreement and have filled out emergency

information on my child(ren).

I hereby grant permission to the Chicago Park District for the use of

any and all photos in which I or my child(ren) may appear (wards of

the State excluded). The usage is inclusive of, but not limited to, the

publication or inclusion in brochures, posters, catalogs, handbooks,

banners, and broadcast or print advertisements. I agree to waive

any claim to compensation for use of said photos.

I agree to allow my information to be entered into a database that

may be used in aggregate for reporting and analysis on this

program.

IDENTITY & RIGHTS AGREEMENT

In consideration of your selection of me as a guest, as a member of a

panel, an interviewee, or as a participant in an event on a sponsored or

unsponsored, radio, television, internet, mobile phone or any other

content platform that currently exists or may be created (or all of the

previously mentioned), I agree to indemnify you, your affiliated media

partners, sponsors or their marketing agencies and officers and employees

of each, and in any way connected with World Sport Chicago, Chicago

2016, the United States Olympic Committee and the International Olympic

Committee, against and hold them and you harmless from any and all

liability, claims, demands, losses and damages arising from any

statement, act, pose, routine or otherwise made by me during my

appearance; further, I grant you the right to use my appearance in

perpetuity and to edit, delete from, add to and use such images,

recordings or portions there of embodying my appearance, voice or

writings at any future times for unlimited radio, television, internet,

mobile phone or any other content platform broadcasting or all of the

above as part of any programming you create, to make unlimited use of

such images, recordings or writings at any future times in all other

entertainment media, to license of my name, likeness and voice in

connection with broadcasting and to exhibit or publish copies of said

photographs or recordings, and to use my name and likeness in

advertising and publicity respecting the program and sponsors thereof and

all other uses of said recordings and images.

I hereby release you and all those listed above from all claims, liability or

actions based liability or actions based upon any use you may make of my

appearance, and further release and discharge you and them from any

and all liability arising out of any injury of any kind, whether to person or

property, which may be sustained by me from my participation in or by

reason of your event or broadcast programs, or by reason of the exercise

of any of the rights granted to you hereunder.

DATE: PRINTED NAME:

SIGNATURE:

ADDRESS:

EMAIL:

PHONE:

PARENTAL SIGNATURE:

(if under 18)