Fw: Paralympic Experience on October 15

[Guest guest]

FYI...here is the attachment:

-

Date: Saturday, October 15, 2011

Location: Square Park

4430 S. Marshfield

4429 S. ina (GPS address)

Chicago, IL 60609

Contact: Tun

daniel.tun@...

312.742.4913 office

312.742.5393 fax

Fax or email registrations by Thursday, October 13th

First 20 people to register will receive a US Paralympic

water bottle and other items!

Open to everyone including students, athletes,

parents, coaches, educators, medical professionals,

etc.

Chicago Park District, 541 N. Fairbanks, 4th Floor, Chicago, IL 60618,

www.chicagoparkdistrict.com

Tun, Special Recreation Coordinator, 312.742.4913

Main Front Office: 312.742.PLAY or 312.747.2001 (TTY)

CHICAGO PARK DISTRICT

PARALYMPIC EXPERIENCE

Schedule of Events

9:00-10:00am Registration

10:00-10:30am Opening Ceremonies

10:45-2:00pm Sport Stations

(Goalball, Judo, Boccia,

Wheelchair Basketball)

2:00-3:00pm Lunch - Free for registered

participants!

3:00-3:30pm Closing Celebration

The Paralympic Experience

The Paralympic Experience is a day-long celebration of Paralympic

sport. The goal of the program is to show individuals with physical and

visual disabilities how participation in sport and living a healthy, active

lifestyle can have a profoundly positive impact on their lives.

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.

PARALYMPIC EXPERIENCE

Individual Registration Form

(One form per participant)

First Name: ________________________ Last Name: __________________________

Age: _________ Date of Birth: _______________ Gender: ? Female ? Male

Address: _______________________________________________________________

City: ____________________________ State: _________ Zip: __________________

Primary Phone: ____________________________ ? Cell ? Home ? Work

Email Address: ______________________________________________________

Sport involvement: ? Recreational ? Developmental ? Emerging ? Elite/National

Sport preference: _________________________________________________________

Sports Classification (s): ___________________________________________________

Disability (if applicable):

? Amputee

? Blind / Visually Impaired

? Cerebral Palsy

? Spina Bifida

? Spinal Cord Injury

? Traumatic Brain Injury / Stroke

? Other (please specify):

_________________________________

Are you a Veteran or active duty service member? ? Yes ? No

? Athlete ? Coach ? Family Member ? Recreation Staff ? Teacher ? Therapist

Waiver and Release of Liability and Publicity

(READ BEFORE SIGNING)

This form must be completed and signed by each person who desires to participate

(athletically, volunteer, or otherwise) in

Paralympic Experience sponsored by the Chicago Park District and U.S.

Paralympics (the " Program " ).

In consideration of being allowed to participate in any of the Programs and

related events and activities, the undersigned

acknowledges and agrees as follows:

I, ___________________________________, HEREBY, FOR MYSELF, AND ON BEHALF OF MY

HEIRS, ASSIGNS,

PERSONAL REPRESENTATIVES, AND NEXT OF KIN, COVENANT NOT TO SUE AND RELEASE, HOLD

HARMLESS,

AND FOREVER DISCHARGE, CHICAGO PARK DISTRICT, U.S. PARALYMPICS, USOC, ANY

CO-SPONSORING ENTITIES

OF THE PROGRAMS, ALL OF THEIR OFFICERS, DIRECTORS, MEMBERS, AGENTS, AND/OR

EMPLOYEES, AND ANY

AND ALL SPONSORS, OFFICIALS, VOLUNTEERS, AND OTHER PARTICIPANTS OF THE PROGRAMS

(COLLECTIVELY,

THE " RELEASEES " ) FROM ANY AND ALL LIABILITY, CLAIMS, DEMANDS, ACTIONS, AND

CAUSES OF ACTION

WHATSOEVER ARISING OUT OF OR RELATED TO ANY LOSS, PROPERTY DAMAGE, OR PERSONAL

INJURY,

INCLUDING DEATH, THAT MAY BE SUSTAINED BY ME OR ANY PROPERTY BELONGING TO ME,

WHETHER

ARISING FROM NEGLIGENCE OF ANY OF THE RELEASEES, OR OTHERWISE, WHILE

PARTICIPATING IN THE

PROGRAMS.

THE RISK OF INJURY FROM THE ACTIVITIES INVOLVED IN THE PROGRAMS IS SIGNIFICANT,

INCLUDING THE

POTENTIAL FOR SERIOUS BODILY INJURY, DEATH, AND PROPERTY DAMAGE. I AM FULLY

AWARE OF THE RISKS

AND HAZARDS ASSOCIATED WITH PARTICIPATING IN THIS ACTIVITY AND I VOLUNTARILY,

KNOWINGLY AND

FREELY, WITHOUT ANY INDUCEMENT OF ANY KIND, ASSUME ALL SUCH RISKS; BOTH KNOWN

AND UNKNOWN,

EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, EXCEPT THAT

WHICH IS THE

RESULT OF GROSS NEGLIGENCE OR WANTON MISCONDUCT, TO THE FULL EXTENT PERMITTED BY

LAW. I

KNOWINGLY AND VOLUNTARILY ASSUME ALL RISKS, BOTH KNOWN AND UNKNOWN, AND ASSUME

FULL

RESPONSIBILITY FOR ANY PERSONAL INJURY, INCLUDING DEATH, THAT MAY BE SUSTAINED

BY ME OR ANY

LOSS OR DAMAGE TO PROPERTY OWNED BY ME AS A RESULT OF BEING ENGAGED IN SUCH

ACTIVITY.I willingly

agree to comply with the stated and customary terms and conditions for

participation. If, however, I observe any unusual, significant

hazard during my presence or participation, I will cease participating and bring

such hazard to the attention of the nearest official

immediately.

In the event that I am unable to do so because of an injury or illness, I hereby

consent to the administration of first aid or other medical

treatment. I agree to assume full responsibility for payment of any and all fees

incurred as a result of such medical treatment. I

understand that all participants in the Programs are required to have their own

medical insurance coverage, and that neither Chicago

Park District , U.S. Paralympics or any other sponsoring entity provide such

coverage.

I hereby voluntarily and without compensation authorize visual images and/or

voice recordings to be made of me by or on behalf of

Chicago Park District, U.S. Paralympics, USOC, and other sponsoring entities

during the Programs. I also authorize the foregoing

entities and their assigns to reproduce, modify, publicize, broadcast and

display any such visual images or voice recordings, with or

without my name, without notice or payment of any royalty, fee, or other

compensation of any character to me for the use of my

image, name or voice.

I hereby covenant not to sue and release the Releasees and their employees,

contractors, licensees and assigns from and against any

and all claims that I may have for invasion of privacy, right of publicity,

defamation, copyright infringement, or any other cause of

action arising out of the use, adaptation, reproduction, distribution,

broadcast, or exhibition of my likeness, name or voice.

This covenant not to sue, release and hold harmless agreement is binding on me,

my heirs, assigns, personal representatives,

administrators, and next of kin.

I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY

UNDERSTAND ITS

TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND

SIGN IT FREELY AND

VOLUNTARILY WITHOUT INDUCEMENT.

Participant's Signature Date

Participant's Printed Name

PART B - PARENT/GUARDIAN WAIVER/RELEASE OF LIABILITY

(If applicant is under eighteen (18) years of age, a parent or guardian must

sign in addition to the above, the following waiver.)

The undersigned, __________________________________, referred to as the parent

and natural or legal guardian of the Participant

does hereby represent that he/she is, in fact, acting in such capacity and

covenants not to sue for and agrees to save and hold harmless

and indemnify each and all of the parties herein referred to above as Releasees

from any and all liabilities and claims for expenses,

damages, or any other losses whatsoever which may be imposed upon said Releasees

because of any defect in or lack of such capacity

to so act and release said Releasees on behalf of the undersigned and the

Participant.

Signature Relationship to Participant Date

Ellen Garber Bronfeld

egskb@...

Paralympic Experience on October 15

Hope that you will join me for this day of Paralympic sport fun hosted by the

Chicago Park District!

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