*required fields
Participant information:
Name*
Sex M  F
Date of Birth* (mm/dd/yy)
Address*
City*
St* Zip*
Email*
Home Phone*
Guardian (if applicable)
Home Phone
Address
City
St Zip
In case of emergency, please notify:
Name*
Home Phone*
Address*
City*
St* Zip*
Physician's Name*
Physician's Phone*
Insurance Information*
Insurance Type Private Insurance Medicaid
Policy #*
Allergies or restrictions, if any
(diabetes, bee stings, etc.)
 List medical conditions
(seizure disorder, cardiac, etc.)
 Special accommodations
Please check one:
I do not need one-to-one assistance throughout the day in order to participate

I need help throughout the day in order to participate. I will bring
a staff person or a family member to provide assistance for me throughout the day

I need help throughout the day in order to participate. Please assign a volunteer to me for the day. (please provide details below)
       
I, the undersigned, represent and warrant that, to the best of my knowledge and belief, I/my ward is physically and mentally able to participate in the event entitled, Yom Sport. I understand that if I/my ward has Downs Syndrome, I/he/she cannot participate in sports or events which by their nature result in hyperextensions, radical flexion or direct pressure on the neck or the upper spine, unless a full radiological examination establishes the absence of atlanto-axial instability.

The organizers of Yom Sport specifically have my permission (both during and anytime thereafter) to use my/my ward's likeness, name, voice and words in television, radio, film, newspaper, magazines and any other media in any form, for the purpose of advertising or communicating the purposes and activities of the event Yom Sport and/or to apply for funds to support those purposes and activities.

If a medical emergency should arise during my/my ward's participation in any Yom Sport activites, and I am not able to give my consent, for whatever reson, I authorize the organizers of Yom Sport to take whatever measures are necessary and which it deems advisable to protect my/my ward's health and well being, including hospitalization.

I have read and fully understand the provisions of the above release and/or have explained the provisions to my ward. I understand that, through my acceptance of the terms of this releasae form, I am agreeing to the above provisions on my own behalf or on behalf of my ward, and hereby give my permission for my ward to participate in Yom Sport games.

I for myself, my heirs, executors and administrators, waive and release any and all claims for damages I may have against the sponsors, organizers and any individuals associated with the event, their successors and assignors and will hold them harmless for any and all injuries suffered in connections with the event Yom Sport.

Participant* I have read and fully understand the provisions of the above release

Guardian (if applicable) I have read and fully understand the provisions of the above release


   

Registration Deadline: August 23, 2010