Summer 2015 - Wilma RUDOLPH Learning Center

Summer
2015
Special Recreation Program Guide
Interested in receiving our quarterly program
book or want more information about the
Chicago Park District Special Recreation
Programs? Contact us at 312.742.5798 or
[email protected]
Visit our Special Recreation webpage at
http://www.chicagoparkdistrict.com/progra
ms/chicago-park-district-special-recreation/
Summer 2015
Chicago Park District
Board of Commissioners
Superintendent & CEO
Bryan J. Traubert, President
Avis LaVelle, Vice President
Erika R. Allen
Donald J. Edward
Tim King
M. Laird Koldyke
Juan Salgado
Michael P. Kelly
City of Chicago
Rahm Emanuel, Mayor
For more information about your Chicago Park District visit
www.chicagoparkdistrict.com 312.742.PLAY or TTY 312.747.2001
Special Recreation Administrative Staff
Gerry Henaghan, CPRP, Special Recreation Manager
[email protected]
312.745.1298
Mike Benavente, CTRS, Special Olympics Administrator
[email protected]
312.747.6274
Ryan Rogers, Special Olympics Program & Event Facilitator
[email protected]
312.747.5678
Riley Bowlin, Special Olympics Program & Event Facilitator
[email protected]
312.745.3195
Michelle LoCoco, CTRS, Senior Program & Event Coordinator
[email protected]
312.745.1121
Emily Verrilli, CTRS, Senior Program Specialist
[email protected]
312.745.1122
Kristi Miller, CPRP, Senior Program & Event Coordinator
[email protected]
312.745.2063
Tamika Jones, CPRP, Program & Event Facilitator
[email protected]
312.745.3188
Dan Tun, Special Recreation Coordinator - Adaptive Sports
[email protected]
312.745.2064
Dan Ferreira, CPRP, Program & Event Facilitator- Adaptive Sports
[email protected]
312.745.2055
Sarah B. Faber, Program Specialist - Deaf and Hard-of-Hearing Programs
[email protected]
Direct Video Phone & Voice 773.796.3525
Adam Tirres, Program & Event Facilitator
[email protected]
312.745.1958
Disability Policy Office
Larry Labiak, Disability Policy Officer
[email protected]
312.742.5097
Annette Dodaja, CPRP, Senior Program Specialist
[email protected]
312.742.4298
CHICAGO PARK DISTRICT
SPECIAL RECREATION
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Special Recreation Coordinators
Bessemer Park
Victor Winson
8930 S. Muskegon Ave
312.747.6023
[email protected]
Mann Park
Chase Park
Fernando Melquiades
4701 N. Ashland Ave
312.742.7518
[email protected]
Marquette Park
Davis Square Park
Christina Moy
4430 S. Marshfield
312.747.6107
[email protected]
McGuane Park
Douglas Park
Valonda Smith
1401 S. Sacramento Dr
773.762.2842
[email protected]
Mt. Greenwood Park
Eckhart Park
Carmen Lopez
1330 W. Chicago Ave
312.746.5085
[email protected]
Norwood Park
Gage Park
Katie Stachura-Hart
2411 W. 55 St
312.747.7635
[email protected]
Piotrowski Park
Harrison Park
Sylvia Herrera
1824 S. Wood
312.746.9581
[email protected]
Shabbona Park
Independence Park
Vittum Park
th
Luis Fuentes
st
2949 E. 131 St
773.646.0009
[email protected]
Colleen Fitzgibbon
6700 S. Kedzie Ave
312.747.6485
[email protected]
Kate McIntosh
2901 S. Poplar
312.747.6497
[email protected]
Lisa Mulcrone
3721 W. 111 St
312.747.6565
[email protected]
st
Chris Sturm
5801 N. Natoma
773.631.4893
[email protected]
David Donohue
4247 W. 31 St
312.745.4804
[email protected]
st
Lori Michalski
6935 W. Addison St
773.685.6388
[email protected]
3945 N. Springfield Ave 773.478.0944
[email protected]
Xochitl Rodriguez
th
5010 W. 50 St
773.284.6022
[email protected]
Jesse Owens Park
Welles Park
Maureen Perez
8800 S. Clyde Ave
312.747.6709
[email protected]
Chelsi Lemaster
2333 W. Sunnyside
312.742.9536
[email protected]
Kosciuszko Park
West Pullman Park
David Bustos
Eileen Guinane
2732 N. Avers
312.742.9954
[email protected]
Rosie St. George
rd
401 W. 123 St
312.747.5744
[email protected]
Loyola Park
Jose Herrera
1230 W. Greenleaf
773.262.7482
[email protected]
Gage Park
Sarah Faber
th
2411 W. 55 St
Direct Video Phone & Voice 773.796.3525
[email protected]
Horner Park
Sarah Faber
2741 W. Montrose
Direct Video Phone & Voice 773.796.3525
[email protected]
Table of Contents
Mission Statement…………………………………………………………………………………………………………….4
General Information………………………………………………………………………………………………………….5-8
Special Events……………………………………………………………………………………………………………………9
Specialty Camps………………………………………………………………………………………………………………..10
Summer Camp Schedule…………………………………………………………………………………………………..11-12
Individuals with a primary diagnosis of deaf or hard-of-hearing…………………………..11
Individuals with a primary physical disability or visual impairment………………………11
Individuals with a primary intellectual or developmental disability………………………11-12
Summer Adaptive Sports Programs At-A-Glance……………………………………………………………….13
Individuals with a primary physical disability or visual impairment………………………13
Individuals with a primary physical disability……………………………………………………….13
Special Olympics Competition Calendar…………………………………………………………………………….14
Participation Forms
Annual Information Forms………………………………………………………………………………….15-17
Special Olympics Medical Application
English…………………………………………………………………………………………………..18-19
Spanish………………………………………………………………………………………………....20-21
3
Mission & Vision Statement
What is Chicago Park District Special Recreation?
The Chicago Park District is a municipal pioneer in offering recreation programs for people with
disabilities. Starting in 1965, the Chicago Park District began training park employees on ways to better
serve people with disabilities. In 1968, the Chicago Park District became the birth place of the Special
Olympics, an organization that now serves athletes with intellectual disabilities in over 170 countries
worldwide. Since then, the park district has expanded its services for individuals with disabilities. With
21 specialty locations serving individuals with intellectual disabilities, 3 specialty locations serving
individuals with a primary physical or visual impairment and 2 specialty locations serving individuals who
are deaf or hard-of-hearing we strive to meet the recreational needs for all individuals with disabilities in
the city of Chicago. The Chicago Park District Special Recreation Department currently offers specialty
programs serving the following populations:
 Intellectual disabilities
 Deaf or hard-of-hearing
 Physical disabilities
 Veterans (Injured, able- bodied
and active duty)
 Blindness or Visual Impairment
**If your family member has special needs and is registered for a traditional program with the Chicago
Park District and may need additional assistance, staffing or adaptive equipment, please contact the
special recreation administrative staff
The Chicago Park District Special Recreation program welcomes all individuals with disabilities, come
and join the fun!!
Chicago Park District
Mission:
 Enhance the quality of life in Chicago by becoming the leading provider of recreation and leisure
opportunities
 Provide safe, inviting and beautifully maintained parks and facilities
 Create a customer-focused and responsive park system that prioritizes the needs of children and families
Core values:
 Children First-Our most important task is to bring children and families into our parks and give them
great reasons to stay and play for a lifetime.
 Best Deal in Town-We prioritize quality in our programs and accountability in our fiscal management
to provide excellent and affordable recreation that invites everyone to come out and play.
 Built to Last-We use our capital to renew our aging infrastructure and leverage partnerships that
produce new parks and facilities that are forward-thinking and world class.
 Extra Effort-We support innovation and welcome new ideas. We believe that professionalism,
communication, technology, and team work serve as the foundation for great customer service and a
productive workplace.
Special Recreation Department
Mission: To enhance the quality of life for children and adults with disabilities through offering a diverse
range of recreational opportunities.
Vision: To promote, foster and encourage physical and mental health through athletic skill development,
recreation and social interactions for youth and adults with disabilities.
4
General Information
REGISTRATION
All participants must register for each session and pay the assigned fee for that session before attending
any program classes. Annual Information Forms need to be filled out at the beginning of each session,
for all participants with intellectual disabilities (of all ages) and for minors with physical disabilities,
visual impairment or deaf or hard-of-hearing. It is required that all first time participants meet with the
Special Recreation Coordinator prior to registration. This is to ensure that the Special Recreation
Program is the proper setting and can meet all specific needs of each individual. The Special Recreation
staff may deem the program inappropriate for an individual based on safety concerns and/or lack of
adherence to program policies. In-person registration is required in order to register for any Chicago
Park District Special Recreation Program. For further information please call the specific park you are
interested in.
Session/Year In-person Registration Begins
Session Begins
Session Ends
Summer 2015
Saturday, April 18, 2015
Week of June 15th
Week of August 17th
**Day camp will start Monday, June 29 and go through Friday, August 7th, 2015**
PAYMENT POLICY
The Chicago Park District accepts the following forms of payment:
 Cash
 Checks (payable to “Chicago Park District”)
 Money Orders (payable to “Chicago Park District”)
 Credit Cards (Visa, MasterCard, Discover and American Express)
REFUNDS
A 15% service charge will be deducted from all refunds and payment cancellations. This includes
duplicate and accidental registrations. All refund requests must be made in-person at the park where
the program is being held, at least two weeks before the program’s scheduled start date. The Chicago
Park District program receipt is required for a refund to be processed. No refund requests will be
accepted after the two week point. Please allow up to six weeks for your refund to be processed.
RETURNED CHECK POLICY
As a user fee payment, a check is an acceptable form of payment two weeks prior to the start of a class
or the rental of a space or room. The two week prior limitation is to ensure sufficient time for the check
to clear the issuer’s bank. If during the check clearing process the check fails, due to lack of funds, a
closed account, etc. the check will be sent back to the Chicago Park District. It is important that the park
or department responsible for the original receipt of the check take appropriate action to contact the
individual or group to collect the amount of the check as well as a $25 returned check fee.
NON-RESIDENT POLICY
Anyone can register for a Chicago Park District program; however, fees are doubled for non-Chicago
residents.
LATE PICK-UP POLICY
There will be a $5 late charge for every 15-minute a participant is picked up late. Each late pick-up will
be documented, and if it happens more than 3 times, park staff reserves the right to dismiss a
participant from the program without a refund. If a parent/guardian intends to pick-up a participant
early, they must notify staff in advance.
5
PARTICIPANT BEHAVIOR GUIDELINES
The Chicago Park District promotes the concept of “equal fun for everyone.” Participants are expected
to exhibit appropriate behavior at all times. The Special Recreation Behavior Guidelines have been
developed to help make the program safe and enjoyable for all participants.
1. Participants must show respect to all other participants and staff.
2. Participants must refrain from using foul language or discussing inappropriate tropics
3. Participants must show respect for equipment, supplies, and facilities
4. Additional rules may be developed for specific programs and athletic leagues as deemed
necessary by staff
Upon infraction of one of these behavior guidelines, a Behavior Incident Report will be completed in
detail by Special Recreation Staff. The following are next step options:
1. No further action at this time
2. Parent/Participant/Staff Meeting
3. Behavior Contract
4. Suspension from program for ____day(s)
5. One-on-one aide is assigned to participant
6. Expulsion from program for the remainder of the session
PARTICIPANT ILLINESS
To prevent the spread of contagious illnesses, it is recommended that participants refrain from
attending a class when any of the following conditions exist:
1. Fever of 100 degrees or higher
2. Vomiting within the past 24 hour
3. Persistent diarrhea in conjunction with other symptom
4. Contagious rash or a rash of unknown origin
5. Persistent cough and/or cold symptoms
6. “Pink eye” (conjunctivitis) or discharge from the eye
7. Symptoms of mumps, measles, chicken pox, strep throat, flu, impetigo, head lice, mites and
ringworm
8. Runny nose with yellow or green discharge, which could indicate an infection
9. Fatigue due to illness, which will hinder participation and full enjoyment of the program
Please notify the Special Recreation staff if a participant contracts any contagious illness that will affect
attendance. After one absence, a participant should return to the program at the recommendation of
his/her doctor, or, if not under a doctor’s care, when symptoms have clearly passed.
MEDICATION POLICY
The Chicago Park District provides the following Medication Policy:
1. If a patron has a condition requires medicine, please contact the Chicago Park District Risk
Management Department at 773.947.0428
2. Patron/Registered participant must provide written instructions from the prescribing
practitioner for the administration of the prescribed medication. Such instructions shall be
signed by the prescribing practitioner.
3. Written instruction should include:
a. The name of the drug/medication
b. The dose
c. Approximate time it is to be taken
6
MEDICATION POLICY (Continued)
d. The diagnosis or reason the medication is needed
e. A list of adverse effect that may be reasonably expected
f. Contraindications to administering the medication
4. A written statement from the prescribing practitioner which identifies the specific
conditions and circumstances under which contract should be made with him or her in
relation to the condition or reactions of the patron receiving the medications, and reflects a
willingness on the part of the patron to accept direct communications from the person
administering the medication.
5. A written statement from the parent/legal guardian authorizing personnel to give
medication
6. Parents should hand-deliver prescribed and over-the counter medication to the Park
Supervisor.
7. The Park Administration reserves the right to require parents to bring and removed
medicine in as necessary. A separate policy and procedure are required for the
administration of medications. The Medication/Treatment Request form, Medication
Record and Physician Care Plan Form are to be filed in the Park prior to any agreement.
8. Administration:
a. If the medication is to be given, staff is to be provided instruction by the physician
or registered nurse and approved; staff must also be willing and able to
demonstration or provide evidence of appropriate learning.
b. Chicago Park District staff and/or adult delivering medication shall document
verification of the medication count by initialing the medication administration
form.
SEVERE WEATHER
In the event of severe weather, cancelling a program/class may be in the best interest of all our
participants. The following guidelines will be used to determine cancellations:
SEVERE COLD
 Outdoor programs: 10 degrees Fahrenheit or in combinations with wind chill of 0 degree
or lower.
 Programs with transportation: Temperature range of 10 degree or in combination with a
wind chill of 0 degree or lower.
 All programs, including indoor: Snowstorm situations when driving restrictions (winter
storm or blizzard warning in which authorities have advised not going out unless
necessary) and emergency accident plans (State and local police) are in effect.
SEVERE HEAT
 Outdoor programs or indoor sites without air-conditioning: Head index of 110 degrees
or higher.
 Programs with transportation:
o Routes for adults with physical disabilities-Heat index of 100degrees or higher.
o All other routes-Heat index of 105 degrees or higher.
 All programs, including indoor: Weather conditions with a tornado warning in effect for
Lake, Will, Cook and/or DuPage Counties
7
ADA COMPLIANCE
In compliance with Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act,
the Chicago Park District does not discriminate on the basis of disability in employment or
admission/access to programs and activities. Further questions or concerns about ADA compliance;
please contact [email protected] or 312.742.4298
ACCESSIBLE FACILITIES
The Chicago Park District is committed to making its facilities accessible to all patrons and visitors.
Offering more than 150 accessible soft- surface playgrounds, 77 swimming pools (both indoor and
outdoor) with either a portable lift, easy access stairs, a zero depth ramp or a combination of amenities;
More than 40 parks offering accessible exercise equipment within their fitness centers and 16 beaches
with accessible walkways allowing all patrons to walk down the edges of Lake Michigan. For more
information on accessible facilities within the Chicago Park District please contact
[email protected] or 312.742.4298
VOLUNTEER OPPORTUNITIES
Interested in working with children and adults with disabilities? Come join our team! Volunteers add to
the success of programs by assisting in weekly programs and special events. If you are interested in
learning more about volunteer opportunities with the Chicago Park District’s Special Recreation
Department, please contact 312.742.5798 or [email protected]
Per the Chicago Park District Policy, all volunteers MUST complete the volunteer application process (including
successfully completeling a background check) prior to be being allowed to volunteer with any Chicago Park
District program. This inlcudes family member of programs participants as well.
BROCHURE CHANGES/ERROR DISCLAIMER
Due to the large amount of information offered in the Chicago Park District’s Special Recreation Program
Book, errors and changes may occur. We apologize for any errors. If you have any questions about
possible program changes or errors please contact the specific park program you are interested in.
8
Special Recreation Triathlon
Swim, bike, run. Repeat. Come out and be a part of a Triathlon relay or do all 3 portions of the race
yourself.
Contact: Kristi Miller, 312.745.2063 or [email protected]
Location: Shabbona Park (6935 W. Addison St)
Date: Sunday, June 7, 2015
Ages: All Ages
Race Begins: 10am
Veteran Family Fest & 16” Softball Tournament
Veterans will compete at the Chicago Park District’s 3rd Annual Veteran Family Fest & Softball
Tournament in hopes to claim the 1st place trophy which currently is held by Jesse Brown VA from 2013.
Bring your family members to watch softball, partake in activities and the event “cook out”
Contact: 312.742.5798 or [email protected]
Location: McGuane Park, 2901 S. Poplar
Date: Saturday, July 18, 2015
Ages: All Ages
Time: 10am-6pm
Midwest Valor Games & Resource Fair
In partnership with the U.S. Department of Veteran Affairs and U.S. Paralympics , come join 3 days of
fun, camaraderie and competition in the City of Chicago. This is a competition opportunity for veterans
and service members with a physical and/or visual disability to learn more about Paralympic sports.
Contact: 312.742.5798 or [email protected]
Dates & Location:
Tuesday, August 18 at Soldier Field
Wednesday, August 19 at Armour Square Park and US Cellular
Thursday, August 20 at Marquette Park
Ages: All Ages
Time: Varies
Paratriathlon Kids Camps
Want to learn more about paratriathlons? Come out and take advantage of this fun opportunity for kids
with a physical disability or visual impairment to enhance their knowledge and paratriathlon skills.
Contact: Dan Tun, 312.745.2064 or [email protected]
Location: 63rd St Beach
Date: July 14-15, 2015
Ages: 6-21
Times: TBD
9
Specialty Camps
For children and adults with disabilities
Sponsored by Variety- the Children’s Charity
SAVE THE DATE
FREE
3 Early Childhood Camps
Ages: 3-7
Locations: TBD
August 10-August 14, 2015
Nature Camp
Ages: 6-12
Location: Peterson Park
August 17-August 21, 2015
Arts Camp
Ages: 10-18
Location: Armour Square Park
August 17-August 21, 2015
Adventure Camp
Ages: 13-21
Location: McGuane Park
August 17-August 21, 2015
For information about registration please contact:
The Special Recreation Department,
312.742.5798 or [email protected]
City of Chicago, Rahm Emanuel, Mayor
Chicago Park District Board of Commissioners
For more information about your Chicago Park District, visit
www.chicagoparkdistrict.com or call 312.742.PLAY, 312.747.2001 (TTY)
10
Special Recreation Summer Camps
Eligibility: Individuals with a primary diagnosis of deaf or hard-of-hearing
Location
Gage Park
Horner Park
Type
Camp Sign
Camp Sign
Ages
6-14
6-14
Fee
$179
$265
Dates
June 23-August 1
June 23-August 1
Days/Times
Mon-Fri, 12pm-6pm
Mon-Fri, 12pm-6pm
Eligibility: Individuals with a primary physical disability or visual impairment
Location
Davis Square Park
Davis Square Park
Type
Day Camp
Teen Leadership
Ages
6-16
16-22
Fee
$82
$11
Dates
June 29-August 7
August 10-14
Days/Times
Mon-Fri, 10am-3pm
Mon-Fri, 10am-2pm
Eligibility: Individuals with a primary intellectual or developmental disability
Location
Bessemer Park
Chase Park
Chase Park
Davis Square Park
Davis Square Pare
Eckhart Park
Eckhart Park
Gage Park
Gage Park
Harrison Park
Harrison Park
Harrison Park
Douglas Park
Independence Park
Independence Park
Independence Park
Jesse Owens Park
Jesse Owens Park
Kosciuszko Park
Kosciuszko Park
Loyola Park
Loyola Park
Loyola Park
Type
Day Camp
Day Camp
Adult Camp
Day Camp
Special Olympics
Sports Camp
Day Camp
Sports Camp
Day Camp
Sports Camp
Day Camp
Day Camp
Special Olympics
Sports Camp
Day Camp
Day Camp
Adult Camp
Teen Leadership
Camp
Early Bird Camp
Day Camp
Day Camp
Ages
8 and up
5-15
16 and up
6-16
Fee
$143
$150
$50
$82
Dates
June 29-August 7
June 29-August 7
June 29-August 7
June 29-August 7
Days/Times
Mon-Fri, 12pm-6pm
Mon-Fri, 9am-3pm
Mon-Fri, 12pm-6pm
Mon-Fri, 10am-3pm
8-15
$10
June 30-August 6
Tues-Thurs, 10am-12pm
8 and up
18 and up
7 and up
8 and up
6-12
12 and up
$97
FREE
$176
$11
$107
$107
June 29-August 7
August 10-21
June 29-August 7
August 10-14
June 29-August 7
June 29-August 7
Mon-Fri, 10am-3pm
Mon-Fri, 10am-4pm
Mon-Fri, 11am-5pm
Mon-Fri, 10am-2pm
Mon-Fri, 10am-3pm
Mon-Fri, 10am-4pm
13 and up
$21
August 10-14
Mon-Fri, 10am-4pm
8-40
8-23
23 and up
$175
$260
$260
June 29-August 7
June 29-August 7
June 29-August 7
Mon-Fri, 10am-4pm
Mon-Fri, 9am-3pm
Mon-Fri, 9am-3pm
14-22
$125
June 29-August 7
Mon-Fri, 9am-3pm
6-21
6-21
6-14
$65
$145
$125
June 29-August 7
June 29-August 7
Mon-Fri, 8am-10am
Mon-Fri, 10am-4pm
Mon-Fri, 9:30am-3:30pm
Night Camp
Day Camp
Special Olympics
Sports Camp
Special Olympics
Sports Camp
15 and up
8-19
$25
$224
June 29-August 7
June 29-August 7
June 29-August 7
Mon-Fri, 2:30pm-8:30pm
Mon-Fri, 9am-4pm
18 and up
$9
July 7-August 4
Tuesday, 5pm-6:30pm
18 and up
$9
Aug 11-Aug 27
Tues & Thurs, 5pm-7pm
11
Location
Mann Park
Marquette Park
Marquette Park
Marquette Park
Marquette Park
Marquette Park
McGuane Park
McGuane Park
Mt. Greenwood Park
Mt. Greenwood Park
Mt. Greenwood Park
Mt. Greenwood Park
Norwood Park
Norwood Park
Piotrowski Park
Piotrowski Park
Shabbona Park
Shabbona Park
Shabbona Park
Vittum Park
Vittum Park
Vittum Park
Welles Park
Welles Park
West Pullman Park
Type
Day Camp
Day Camp
Night Camp
Special Olympics
Golf Camp
Special Olympics
Bocce Camp
Special Olympics
Volleyball Camp
Day Camp
Sports Camp
Day Camp
Adult Camp
Adult Camp
Adult Camp
Day Camp
Sports Camp
Day Camp
Day Camp
Day Camp
Day Camp
Night Camp
Day Camp
Adult Camp
Sports Camp
Day Camp
Sports Camp
Day Camp
Ages
8 and up
6-22
16 and up
Fee
$128
$240
$110
Dates
June 29-August 7
June 29-August 7
June 30-August 6
Days/Times
Mon-Fri, 10am-4pm
Mon-Fri, 9:30am-3:30pm
Tues-Thurs 4pm-8pm
8 and up
$6
June 29-August 3
Monday, 4pm-6pm
8 and up
$6
Aug 18-Sept 17
Tues & Thurs, 5pm-5:45pm
8 and up
$6
Aug 18-Sept 17
Tues & Thurs, 6pm-6:45pm
8 and up
8 and up
7-15
16 and up
16 and up
16 and up
6-15
15 and up
8 and up
17 and up
8-13
13-17
17 and up
6-14
14 and up
8 and up
8 and up
8 and up
6-27
$205
$20
$261
$16
$51
$51
$258
$258
$145
$100
$257
$257
$257
$110
$40
FREE
$152
FREE
$300
June 29-August 7
August 10-14
June 29-August 7
July 1-August 5
July 2- August 6
July 3-August 7
June 29-August 7
June 29-August 7
June 29-August 7
June 29-August 7
June 29-August 7
June 29-August 7
June 29-August 7
June 29-August 7
June 29-August 7
Aug 25-Sept 17
June 29-August 7
August 24-28
June 29-August 7
Mon-Fri, 10am-4pm
Mon-Fri, 10am-4pm
Mon-Fri, 10am-3:15pm
Wednesday, 4pm-6pm
Thursday, 4pm-8:30pm
Friday, 3:45pm-5:15pm
Mon-Fri, 9am-3pm
Mon-Fri, 12pm-6pm
Mon-Fri, 10am-4pm
Mon-Fri 3pm-8pm
Mon-Fri, 9am-3pm
Mon-Fri, 9am-3pm
Mon-Fri, 2:30pm-8:30pm
Mon-Fri, 10am-4pm
Mon-Fri, 10am-4pm
Tues-Thurs, 4pm-7pm
Mon-Fri, 9:30am-3:30pm
Mon-Fri 2pm-4m
Mon-Fri, 8am-6pm
**For more information about Chicago Park District Special Recreation year round programming,
please visit our website at http://www.chicagoparkdistrict.com/programs/chicago-park-districtspecial-recreation/ or contact us at 312.742.5798 or [email protected]**
12
Summer Adaptive Sports Programs-At-A-Glance
Eligibility: Individuals with a primary physical disability or visual impairment
31st Street Harbor
4247 W. 31st St, Chicago, IL
Contact: Dan Tun, Special Recreation Coordinator
312.745.2064 ∙ [email protected]
Tuesday
Paratriathlon Training
Thursday
Paratriathlon Training
13 and over
3:30pm-6:00pm
13 and over
3:30pm-6:00pm
Eligibility: Individuals with a primary physical disability
McFetridge Sports Center
3843 N. California Ave, Chicago, IL 60618
Contact: Dan Tun, Special Recreation Coordinator
312.745.2064 ∙ [email protected]
Wednesday
Sled Hockey
13 and over
9:35pm-10:45pm
Eligibility: Individuals with a primary physical disability
California Park
3843 N. California Ave, Chicago, IL 60618
Contact: Dan Ferreira, Program & Event Facilitator
312.296.5973 ∙ [email protected]
Tuesday
Wheelchair Softball
Wheelchair Softball
Saturday
Wheelchair Softball
Ages: 6-19
Ages: 18 and over
2:30pm-5:30pm
6:00pm-8:30pm
Ages: 18 and over
10:00am-1:00pm
Washington Park
5531 S. Martin Luther King Dr, Chicago, IL 60637
Contact: Dan Ferreira, Program & Event Facilitator
312.296.5973 ∙ [email protected]
Saturday
Wheelchair Basketball League
Ages: 15 and over
9:00am-5:00pm
13
SPECIAL OLYMPCIS CHICAGO
2015 SUMMER COMPETITION SCHEDULE
Date/Event
Location
July
7 Softball Skills Competition
Grant Park (Upper Hutchinson Field)
9 Softball Team Competition
Grant Park (Lower Hutchinson Field)
21 Golf Course Play Competition
South Shore Cultural Center
23 Golf Skills Competition
Marquette Park Golf Training Center
August
Week of 17th Gymnastic Camps
Peterson & Harrison Park
14
CHICAGO PARK DISTRICT
SPECIAL RECREATION
ANNUAL INFORMATION FORM (A.I.F.)
THE A.I.F. CONTAINS EXTREMELY IMPORTANT PARTICIPANT INFORMATION WHICH IS NECESSARY
FOR THE CHICAGO PARK DISTRICT SPECIAL RECREATION STAFF TO PLAN AND EXECUTE SAFE AND ENJOYABLE PROGRAMS.
THIS FORM IS MANDATORY AND WILL HELP THE STAFF SERVE THE PARTICIPANT BETTER AND SAFER.
THIS FORM MUST BE COMPLETED AT THE BEGINNING OF A SESSION, SIGNED, DATED & UPDATED PER SESSION –COMPLETING A NEW FORM ANNUALLY.
PLEASE ANSWER ALL THE QUESTIONS IN THEIR ENTIRETY (PLEASE PRINT).
DATE: ___________________
PAGE 1 OF 3
PARTICIPANT INFORMATION (PLEASE PROVIDE CURRENT PHOTOGRAPH)
SEC. A
FIRST NAME ________________________
MIDDLE NAME _______________________
LAST NAME _________________________
IS PARTICIPANT HIS/HER OWN GUARDIAN?
□ YES
□ NO
NICKNAME _________________________________
AGE __________
STREET ADDRESS_____________________________________
CITY _______________
PHONE __________________
EMAIL ___________________________________
DATE OF BIRTH ____/____/____
GENDER □M OR □F
HEIGHT ______
PRIMARY DIAGNOSIS _____________________________________
STATE ___________
ZIP _____________
PRIMARY LANGUAGE USED AT HOME___________
WEIGHT ______
HAIR COLOR _______
EYE COLOR_______
SECONDARY DIAGNOSIS __________________________________
CURRENT MEDICATIONS (DOSE& FREQUENCY) __________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
ALLERGIES _____________________________________________
DIETARY RESTRICTIONS __________________________________
IS PARTICIPANT SUBJECT TO SEIZURES? □ YES
□ NO TYPE & FREQUENCY _____________________ DATE OF LAST SEIZURE ____/____/____
DOES PARTICIPANT REQUIRE REST AFTER SEIZURE? □ YES □ NO ANY SEIZURE CONTROLLED MEDICATION? □ YES □ NO IF YES, NAME:___________
DOES PARTICIPANT HAVE ANY DOCTOR RESTRICTIONS?
□ YES
□ NO
IF YES, PLEASE EXPLAIN ___________________________________
IF PARTICIPANT HAS DOWN SYNDROME, HAS HE/SHE BEEN TESTED FOR ATLANTOAXIAL INSTABILITY?
IF YES, WERE THE RESULTS POSITIVE?
□ YES □ NO
MOBILITY
□ WALKS INDEPENDENTLY
□ CANE
□ DENTURES
□ GLASSES
CHECK ALL THAT APPLY:
□ YES
□ NO
□ USES MANUAL WHEELCHAIR
□ USES MOTORIZED WHEELCHAIR
□USES OTHER DEVICES
□ BRACES
□ WALKER
□ CRUTCHES
□ CONTACT LENSES
□ ORTHOPEDIC DEVICES
□ PROSTHESIS
□ OTHER ________________________ EXPLAIN_______________________
CONTACT INFORMATION
SEC. B
PRIMARY CONTACT
FIRST, MIDDLE & LAST NAME __________________________________________________ RELATIONSHIP _______________________
ADDRESS STREET_____________________________________
CITY _______________
STATE ___________ ZIP _____________
EMAIL _____________________________________________________________________________________________________
PHONE #
□ HOME _________________________
□ CELL _________________________ □ WORK ________________________
**PLACE A CHECKMARK BESIDE THE PHONE NUMBER YOU WOULD LIKE US TO USE FIRST**
SECONDARY CONTACT
FIRST, MIDDLE & LAST NAME __________________________________________________ RELATIONSHIP _______________________
ADDRESS STREET_____________________________________
CITY _______________
STATE ___________ ZIP _____________
EMAIL _____________________________________________________________________________________________________
PHONE #
□ HOME _________________________
□ CELL _________________________ □ WORK ________________________
**PLACE A CHECKMARK BESIDE THE PHONE NUMBER YOU WOULD LIKE US TO USE FIRST**
DOCTOR’S NAME ___________________________________________________________
MEDICAL INSURANCE_________________________________________
PHONE
_________________________
POLICY NUMBER ____________________________________
SCHOOL/PLACE OF EMPLOYMENT ________________________________________
GROUP HOME/RESIDENTIAL FACILITY_____________________________________
TEACHER/SUPERVISOR _________________________
MANAGER/CASE WORKER ______________________
CHICAGO PARK DISTRICT
SPECIAL RECREATION
ANNUAL INFORMATION FORM (A.I.F.)
PAGE 2 OF 3
DAILY LIVING SKILLS
EATING
BATHROOM
DRESSING
□ EATS INDEPENDENTLY
□ TOILETS INDEPENDENTLY
□ DRESSES INDEPENDENTLY
SEC. C
□ NEEDS ASSISTANCE EXPLAIN __________________________
□ NEEDS ASSISTANCE EXPLAIN __________________________
□ CANNOT DRESS INDEPENDENTLY EXP. ___________________
□ NEEDS TO BE MONITORED
□ NEEDS TO BE MONITORED
□ NEEDS SOME ASSISTANCE
COMMUNICATION
□ VERBAL: SPEAKS CLEARLY □ VERBAL: DIFFICULT TO UNDERSTAND
□ HAS DIFFICULTY EXPRESSING NEEDS □ GESTURES/POINTS
□ USES SIGN LANGUAGE
□ USES HEARING DEVICES/HEARING AIDS □ USES A COMMUNICATION BOARD/SCHEDULE/PICTURES
EXPLAIN: _______________________________________________________________________________________________________
TRANSPORTATION □ SCHOOL BUS
□ PARENTS/GUARDIANS DROP-OFF
OTHER_______________________________________________
**CHECK ALL THAT APPLY**
□ CDT/PACE
ALLOWED TO SELF-TRANSPORT?
□ YES □ NO
EXPLAIN ______________________________________________
INTERACTION/SOCIALIZATION SKILLS
SEC. D
SWIMMING
□ SWIMS INDEPENDENTLY
□ CAN SWIM A LITTLE
□ CANNOT SWIM AT ALL
□ EXTREME FEAR OF WATER
EXPLAIN _______________________________________________________________________________________________________
SOCIAL INTERACTION
□ INITIATES SOCIAL INTERACTION ON OWN □ SOCIALIZES WITH VERBAL PROMPTING □ AVOIDS SOCIAL INTERACTIONS
EXPLAIN _______________________________________________________________________________________________________
PREFERS BEING
□ ALONE
□ WITH PEERS
□ WITH ADULTS
EXPLAIN ___________________________________
IS MOST SUCCESSFUL IN □ LARGE GROUPS
□ SMALL GROUPS
□ OTHER
EXPLAIN ___________________________________
RESPONDS BETTER TO
□ MALES
□ FEMALES
□ EITHER
EXPLAIN ___________________________________
PLEASE LIST ANY SENSORY ISSUES THE PARTICIPANT MAY HAVE: _________________________________________________________________
_______________________________________________________________________________________________
BEHAVIOR/ CONDUCT
SEC. E
FOLLOWING DIRECTIONS
□ CAN FOLLOW DIRECTIONS INDEPENDENTLY □ NEEDS VERBAL PROMPTING □ NEEDS STEP-BY-STEP ASSISTANCE – EXP. BELOW
EXPLAIN: _______________________________________________________________________________________________________
CHECK ALL THAT
APPLY:
□ SHORT ATTENTION SPAN
□ MANIPULATIVE
□ TAKES OTHER PEOPLES
□ EASILY DISTRACTED
□ VERBAL OUTBURST
□ TANTRUMS/MELTDOWNS
□ HYPERACTIVITY
□ INSTIGATES BEHAVIOR
□ OPPOSITIONAL/DEFIANT
□ TENDENCY TO WANDER OFF
□ SELF-ABUSIVE BEHAVIORS
□ PHYSICAL AGGRESSION TO OTHERS
BELONGINGS
□ HITTING
□ PUSHING
□ SPITTING
□ BITING
□ KICKING
□ HAIR PULLING
□ THROWING
□ SCRATCHING
□ TAPPING/STEMMING
□ REPETITIVE BEHAVIORS
□ LIST OTHER INAPPROPRIATE BEHAVIORS HERE: ____________________________________________________________________________
IF YOU CHECKED YES TO ANY BEHAVIORS ABOVE, PLEASE PROVIDE A DETAILED EXPLANATION:_____________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
WHAT ARE KNOWN TRIGGERS TO THE BEHAVIORS ABOVE:____________________________________________________________________
____________________________________________________________________________________________________________
DOES THE PARTICIPANT RESPOND TO SPECIFIC BEHAVIOR MANAGEMENT TECHNIQUES USED AT HOME, SCHOOL, OR WORK? □ YES □ NO
EXPLAIN: ______________________________________________________________________________________________________
_____________________________________________________________________________________________________________
DOES THE PARTICIPANT HAVE UNUSUAL FEARS OR CONCERNS? □ YES □ NO EXPLAIN: ________________________________________________
CHICAGO PARK DISTRICT
SPECIAL RECREATION
ANNUAL INFORMATION FORM (A.I.F.)
PAGE 3 OF 3
SAFETY- REGARDING THE PARTICIPANT
WILLING TO STAY WITH THE GROUP?
CAN RECOGNIZE DANGER?
MAY WANDER OR RUN?
CAN MANAGE OWN MONEY?
CAN BE RESPONSIBLE FOR OWN BELONGINGS?
SEC. F
□ YES
□ YES
□ YES
□ YES
□ YES
□ NO
□ NO
□ NO
□ NO
□ NO
ADD ANY ADDITIONAL INFORMATION NOT ALREADY NOTED IN THE ANNUAL
INFORMATION FORM IN THIS SECTION:
CUT/PASTE CURRENT PHOTO HERE
DATE PHOTO INSERTED: ___________________________
THIS FORM MUST BE COMPLETED AT THE BEGINNING OF A SESSION, SIGNED, DATED & UPDATED PER SESSION
WINTER SESSION – YEAR ________
□ CHECK/SKIP IF NOT REGISTERED
___________________________________________________________________________
__________________________
SIGNATURE OF PARTICIPANT/GUARDIAN/PARENT
DATE
___________________________________________________________________________
□
PRINT NAME
SR STAFF INITIALS
SPRING SESSION – YEAR ________
□ CHECK/SKIP IF NOT REGISTERED
___________________________________________________________________________
SIGNATURE OF PARTICIPANT/GUARDIAN/PARENT
___________________________________________________________________________
PRINT NAME
SUMMER SESSION – YEAR ________
□ CHECK/SKIP IF NOT REGISTERED
___________________________________________________________________________
SIGNATURE OF PARTICIPANT/GUARDIAN/PARENT
___________________________________________________________________________
PRINT NAME
FALL SESSION – YEAR ________
□ CHECK/SKIP IF NOT REGISTERED
___________________________________________________________________________
SIGNATURE OF PARTICIPANT/GUARDIAN/PARENT
___________________________________________________________________________
PRINT NAME
__________________________
DATE
□
SR STAFF INITIALS
__________________________
DATE
□
SR STAFF INITIALS
__________________________
DATE
□
SR STAFF INITIALS
A NEW A.I.F. SHOULD BE COMPLETED ANNUALLY
**NOTE: THE ANNUAL INFORMATION FORM MUST BE COMPLETED AT THE BEGINNING OF THE FIRST SESSION. PLEASE LET US KNOW IF ANY INFORMATION CHANGES
DURING THE YEAR. ALL APPLICABLE MEDICAL FORMS MUST BE COMPLETED/UPDATED EACH SEASON. PLEASE NOTIFY US OF CHANGES IN MEDICATION THAT OCCUR
DURING THE YEAR**
APPLICATION FOR PARTICIPATION IN SPECIAL OLYMPICS ILLINOIS
Valid Application for Participation is mandatory for all competitors
605 E. Willow St.  Normal, IL 61761-2682  309-888-2551
ATHLETE INFORMATION
SO ILL Rev. 8-1-10
Birthdate
M
M
D
Athlete Name (last name, space, first name)
SO ILL OFFICE ONLY
MEDICAL CLEARANCE
D
Y
Y
PLEASE CHECK MEDICAL INFORMATION
Agency Name
Sex (M or F)
Athlete’s Mailing Address
Parent’s/Guardian’s (Please Circle One) Home Address
Athlete’s City
Parent’s/Guardian’s City
State
Zip Code
-
Ethnicity
White
Hispanic/Latino
Does the athlete have or is the athlete:
Heart Problems
Yes
Diabetic
Yes
Epileptic/Seizures
Yes
Blind
Yes
Deaf
Yes
Hepatitis
Yes
Other
Zip Code
State
Black/African American
Other
Asian
Parent’s/Guardian’s
Home Telephone
-
-
HEALTH INSURANCE & EMERGENCY INFORMATION (Required for Processing)
Person to be contacted
in case of emergency
Emergency
Contact Phone (
Medical Insurance Company
Policy Number
Does athlete have Down Syndrome?
Yes
No
If yes, have x-rays of the C1-C2 vertebrae
been taken and examined?
Yes
No
Date of x-ray
Is the athlete clear of Atlantoaxial Instability?
Yes
No
Current Medication
)
No
No
No
No
No
No
Dosage
PARENT AND/OR GUARDIAN AUTHORIZATION AND MEDIA RELEASE
I, on my own behalf or as the undersigned parent and/or legal guardian of the above named applicant (hereafter referred to as the “Entrant”), hereby request permission for the
Entrant to participate in Special Olympics programs. I acknowledge that Special Olympics will screen all entrants using the Sex Offender Public Registry and the Child Murder and
Violent Offender Against Youth Registry and understand that entrants listed on either Registry will be denied participation. I affirm that this Entrant has never been on said Registries
or, if Entrant was listed on either Registry but has since been removed, I will contact Special Olympics Illinois for instructions before submitting this application.
I represent and warrant to you that the Entrant is physically and mentally able to participate in Special Olympics, and I submit herewith a subscribed medical certificate. I understand that
if the athlete has Down Syndrome, he/she cannot participate in sports or events which, by their nature result in hyper-extension, radical flexion or direct pressure on the neck or upper
spine unless a full radiological examination establishes the absence of Atlantoaxial Instability. I am aware that the sports and events for which this radiological examination is required
are equestrian sports, artistic gymnastics, diving, pentathlon, high jump, alpine skiing, soccer, soccer skills, powerlifting squat and butterfly stroke and diving starts in swimming.
On behalf of the Entrant and myself, I acknowledge that the Entrant will be using facilities at his/her own risk and I, on my own behalf, herby release, discharge and indemnify
Special Olympics from all liability for injury to person or damage to property of myself and Entrant.
In permitting the Entrant to participate, I am specifically granting permission to Special Olympics Illinois to use the likeness, voice and words of the Entrant in television, radio, films,
newspapers, magazines and other media, and in any form not heretofore described, for the purpose of advertising or communicating the purposes and activities of Special
Olympics and in appealing for funds to support such activities. I understand that by signing below I consent for the Entrant to participate in the Special Olympics Healthy Athletes
Program that provides individual screening assessments of health status and health care needs. The Entrant has no obligation to participate and I understand the Entrant should
seek his/her own medical advice and assistance and Special Olympics is not responsible for the Entrant’s health.
If I am not personally present at Special Olympics activities in which the Entrant is to compete, so as to be consulted in case of necessity, you are authorized on my behalf and at
my account to take such measures and arrange for such medical and hospital treatment as you may deem advisable for the health and well-being of the Entrant.
I, THE UNDERSIGNED ADULT ENTRANT, have read and fully understand the
I, THE UNDERSIGNED PARENT AND/OR GUARDIAN of the above specified
provisions of the above release and/or have had them explained. I hereby agree that I
Entrant, have read and fully understand the provisions of the above release and have
will be bound thereby and I shall defend Special Olympics Illinois and hold it harmless
explained them to said Entrant. I hereby agree that I and said minor will be bound
from disaffirmation thereof.
thereby, and I shall defend Special Olympics Illinois and hold it harmless from any
disaffirmation thereof by said minor.
Entrant
Witness
Date
Athlete’s Email Address
Signature of Parent
and/or Legal Guardian
(Check appropriate box)
Print Name
Parent’s Email Address
Allergies to medication, if any:
Date of last Tetanus shot:
I have examined the above-named Entrant
and, in my opinion, there is no mental or
physical reason why he or she should not
participate in the Special Olympics sports
training and competition program. Further
information will be forwarded if required.
Current medication, if any, is specified with
dosage on this application.
Examination Date
Doctor’s Signature
Print Name
Address
City
State
Zip
Date
Phone (
)
Original parent/guardian and doctor signatures are required by the office of Special Olympics Illinois. Faxed signatures will not be accepted.
Instructions for Completing the Application for Participation
The Application for Participation (App) must be filled in completely. Apps with blank sections or attachments (exception: letter from State Office of Guardianship, 2a below) will not be accepted.
This App is valid for 2 years from the date of the examination date, regardless of the parent/guardian/Entrant signature date.
Parent/guardian and doctor signatures must be original and both original signatures must be on the same App form. Faxed
signatures, phone consents or verbal consents will not be accepted.
If Entrant was listed on the Sex Offender Public Registry or the Child Murder and Violent Offender Against Youth Registry
but has since been removed, contact the Special Olympics Illinois office for instructions before submitting this application.
ATHLETE INFORMATION AND HEALTH INSURANCE & EMERGENCY INFORMATION
1. The first two sections must be filled in completely. The ethnicity information is requested to assist in the organizational outreach
efforts.
PARENT AND/OR GUARDIAN AUTHORIZATION AND MEDIA RELEASE
2. The Parent or Legal Guardian must read, sign and date the Parent/Guardian Authorization and Media Release.
a. The section must be signed and dated as printed. Deletions or alterations to the section will result in an invalid App.
(Exception: Deletion of the last paragraph regarding medical treatment and attachment of a letter of explanation and 24-hour emergency telephone numbers from the State Office of Guardianship. As of January 1, 1987, the letter of explanation must be
attached.)
b. Only one of the two signature blocks must be completed. Special Olympics Illinois works under the understanding that this
section may be signed by either:
The (biological or adoptive) parent unless the athlete has been designated a ward of the state;
OR
The legal guardian; this person must be legally assigned for the individual;
OR
The athlete if he/she is over the age of 18 and has not been designated as needing and having been assigned a legal guardian.
A witness signature is necessary if the athlete’s signature is unrecognizable (for example, if the athlete’s signature is an “X.”)
MEDICAL CLEARANCE
3. The Medical Clearance section must be completed, signed and dated by a medical practitioner licensed to administer physical
examinations by the state in which he/she practices. As of September 1, 1990, the Special Olympics Illinois Application for
Participation is the only Medical Clearance form which will be accepted as valid by Special Olympics Illinois.
This person, by signing the Medical Clearance, is stating that the athlete is in good health and can safely participate in Special
Olympics sports training and competition. It is strongly suggested that the person administering the physical examination possess the
following:
Background and preparation in giving sports physical examinations.
Qualifications to administer examinations that would not compromise his/her area of specialty.
AFTER COMPLETING THE APPLICATION ...
4. Send the original copy of the Application for Participation to the Area Director who will send the App to the Special Olympics
Illinois Chapter office. The Chapter office will validate the Application for Participation and send a copy of the App with an
approved stamp back to the SOAD (Special Olympics Athletic Director). An Application for Participation will not be validated until
all information is correct and completed on the approved form.
5. Special Olympics Illinois requires that all Applications for Participation be presented prior to and no later than the established
Medical App deadline of a Chapter championship level event (Winter Games, State Basketball Tournament, Summer Games,
Outdoor Sports Festival, Fall Games, Floor Hockey or State Bowling Tournament). All Apps for the event in question must be valid
throughout the completion of that Chapter competition.
Applications for Participation for athletes participating in District Tournaments and Sectional Tournaments must be received before
the entry deadline or with registration materials.
Applications not on file or in receipt by the specified deadline will not be accepted.
SOLICITUD DE PARTICIPACIÓN EN OLIMPÍADAS ESPECIALES DE ILLINOIS
Es obligatoria para todos los participantes una Solicitud de Participación válida
605 E. Willow St. • Normal, IL 61761 • 309-888-2551
INFORMACIÓN DEL ATLETA
SO ILL Rev. 8-1-10
APROBACIÓN MÉDICA
Fecha de nacimiento
M M D D Y Y
Nombre del atleta (apellido espacio nombre)
Nombre de la agencia
Sexo (M o F)
Domicilio Postal del Atleta
Domicilio de la casa de los padres o guardián (Por Favor Círculo Uno)
Ciudad del atleta
Ciudad de los padres o guardián
Estado
Estado
Código Postal
¿Tiene el atleta la aprobación de la
Inestabilidad Atlanto-Axial? (Is the athlete clear
-
Ethnicity
-
Negro/Afroamericano
Blanco
Etnicidad Hispano/Latino
Other
Asiático
of Atlantoaxial Instability?)
-
¿Es o tiene el atleta?: (Does the athlete have or
Sí No
is the athlete:)
Problemas del corazón (Heart Problems)
Diabético (Diabetic)
Epilépsia/Ataques epilepticos
-
INFORMACIÓN SOBRE EL SEGURO DE SALUD Y EMERGENCIAS (Requerido para Procesamiento)
Teléfono
de emergencia
(
Número de póliza
En caso de emergencia
avisar a
Compañía de seguro médico
)
AUTORIZACIÓN PATERNAL O DEL GUARDIÁN Y EL PERMISO PARA LA PRENSA
Yo, en mi propio nombre o como el suscrito padre/guardián legal del solicitante mencionado arríba (desde aquí en adelante referido como el “Participante”) por el
presente, pido permiso para la participación del entrante o Participante para que tome parte en los programas de Olimpíadas Especiales. Yo reconozco que
Olimpíadas Especiales investigará a todos participantes utilizando el Registro Público de Infractores Sexuales o el Registro de Asesinatos a Menores y Delincuentes
Violetos Contra Jóvenes y yo entiendo que todos participantes que aparecen en alguno de estos registros serán negados de participar. Yo afirmo que el presente
particpante nunca ha aparecido en los mencionados registros o, si el participante estuvo inscrito en cualquier de estos registros, entiende que a los participantes
inscritos en cualquier de estos registros se les negará participación. Afirmo que el presente participante nunca ha aparecido inscrito en los mencionados registros.
Yo represento y garantizo a ustedes que el Participante está física y mentalmente apto para participar en Olimpíadas Especiales, y entrego con esto un
certificado médico del Participante. Entiendo que si el atleta tiene el Síndrome de “Down,” él o ella no podrá tomar parte en los deportes o juegos que, por
su propia naturaleza podrían resultar en hipertensión, flexión radical o presión directa en el cuello o la parte alta de la columna vertebral a menos que una
radiografía establezca la ausencia de la Inestabilidad Atlanto-Axial. Estoy consciente de que los deportes o juegos para los cuales esta radiografía es
necesaria son los deportes ecuestres, los ejercicios gimnásticos sin aparatos, los clavados, el pentatlón, la “mariposa” y los clavados básicos de la natación,
el salto alto, la esquíe de montaña, futbol soccer, habilidades de futbol soccer y halterofilia.
En nombre del Participante y del mio propio, reconozco que el Participante va a estar usando instalaciones por su propia riesgo y yo, por mi propia parte, doy permiso, descargo o exonero, y no cobraré ninguna indemnización a Olimpíadas Especiales por ninguna lesión a la persona o daño mi propiedad y del Participante.
Al permitir la participación del Participante, estoy específicamente dando permiso a ustedes para usar la apariencia, la voz y las palabras del Participante en la televisión, radio, cine, periódicos, revistas y otros medios de información y en cualquier forma hasta ahora no descrita, para los propósitos de la publicidad o de comunicación de los propósitos y actividades de Olimpíadas Especiales y al pedir fondos para apoyar tales actividades. Tengo amplio conocimiento de que al firmar en el
espacio provisto estoy dando mi consentimiento para que el principiante participe en el Programa de Atletas Sanos de Olimpiadas Especiales, mismo que proporciona pruebas individuales de estatus de salud y asesoría en cuanto a cuidados de salud. El Participante no tiene la obligación de participar y tengo amplio
conocimiento de que yo debo consultar mi propia opinión y asistencia médica y de que Olimpiadas Especiales no se hace responsable por la salud del Participante.
Si yo no estoy presente personalmente en las actividades de Olimpíadas Especiales en las cuales el Participante va a competir, como para consultárseme
en caso de necesario, ustedes están autorizados en mi nombre y por mi cuenta a fin de tomar tales medidas y arreglar el tratamiento médico y hospitalización que ustedes juzguen aconsejable para la salud y el bienestar del Participante.
YO, EL PARTICIPANTE ADULTO Y FIRMANTE he leído y entiendo compleYO, EL FIRMANTE PADRE Y/O GUARDIÁN LEGAL DEL PARTICIPANTE, he
tamente las provisiones del permiso arriba mencionado y/o que me ha sido
leído y totalmente entendido las provisiones del permiso arriba mencionado y se las
explicado. Yo, de esta manero estoy de acuerdo que yo y el Participante
he explicado al Participante. Yo, de esta forma estoy de acuerdo que yo y el menor
estaremos limitados y condicionados por este acuerdo y yo les defenderé a
estaremos limitados por este acuerdo y yo les defenderé a ustedes y no haré
ustedes y no haré ningún cargo de cualquier desafirmación que yo haga.
ningún cargo de cualquier desafirmación o afirmación contraría que el menor haga.
Entrante
Testigo
La dirección electrónica del participante
Fecha
Firma del padre
o guardián
(Márque con una cruza las cassilla apropiada)
Nombre (letra de molde)
La dirección electrónica de los padres
(MEDICAL CLEARANCE)
FAVOR DE CHEQUEAR LA INFORMACIÓN
MÉDICA (PLEASE CHECK MEDICAL INFORMATION)
Sí No
Síndrome de Down (Down Syndrome)
Si el atleta padece el Síndrome de Down,
¿se ha tomado y hecho radiografías, o
rayos X de las vértebras C1-C2? (If athlete is
Down Syndrome, have x-rays of the C1-C2
vertebrae been taken and examined?)
Fecha de los rayos X (Date of x-ray)
Código Postal
Telefono de casa de
los padres o guardián
SÓLO PARA USO DE LA OFICINA (SO ILL OFFICE)
(Epileptic/Seizures)
Invidente (Blind)
Sordo (Deaf)
Hepatitis (Hepatitis)
Otros (Other)
Medicina que toma actuamente Dosis
(Current Medication)
(Dosage)
Alergias a medicinas (si tiene alguna):
(Allergies to medication, if any:)
Fecha de la última inyección para el Tetano
(Date of last Tetanus shot:)
I have examined the above-named Entrant
and, in my opinion, there is no mental or
physical reason why he or she should not
participate in the Special Olympics sports
training and competition program. Further
information will be forwarded if required.
Current medication, if any, is specified with
dosage on this application.
Examination Date
Signature
Print Name
Address
Fecha
City
Phone (
State
Zip
)
Las firmas originales de los padres/tutores y doctores son requeridas por la oficina de las Olimpíadas Especiales de Illinois. Aquellas firmas que sean enviadas por fax no serán aceptadas.
Instructiones Para Completar La Solicitud De Participación
La Solicitud de Participación (SP) tiene que ser llenada completamente; no se aceptarán los formularios con secciones o documentos
en blanco (excepción: la carta de la Oficina de Guardianía del Estado, 2A abajo).
Esta solicitud es válida durante dos años, a partir e incluyendo la fecha de la examinación física, sin importar la fecha de la firma del
padre, guardián o del participante o entrante.
Las firmas del Padre/Tutor y Doctor deben ser originales y ambas firmas originales deben aparecer en el mismo documento de aplicación. Aquellas firmas
que sean enviadas por fax no serán aceptadas.
Yo afirmo que este participante nunca ha aparecido inscrito en los mencionados registros o, si el participante fue listado en el Registro Público de Infractores
Sexuales o el Registro de Asesinatos a Menores y Delincuentes Violetos Contra Jóvenes pero ha estado tachado de la lista, yo contactaré a Olimpíadas
Especiales de Illinois para más instrucciones antes de entregar esta solicitud.
INFORMACIÓN DEL ATLETA E INFORMACIÓN SOBRE EL SEGURO DE SALUD Y DE EMERGENCIA
1. La primera sección tiene que llenarse completamente. La información optativa sobre la etnicidad es solicitada para ayudar en los
esfuerzos organizativos de divulgación.
AUTORIZACIÓN PATERNAL Y/O DEL GUARDIÁN Y LA PUBLICACIÓN EN LOS MEDIOS
2. El padre o el guardián legal tiene que leer, firmar y fechar la Autorización Paternal o del Guardián y la Publicación en los Medios.
a. Esta sección debe firmarse y fecharse. Las omisiones o alteraciones en esta sección invalidarán la SP. (Excepción: Omisión
del último párrafo sobre el tratamiento médico y la adhesión de un carta explicativa, el número de teléfono de emergencia
durante las 24 horsas de la Oficina de Guardianía del Estado. La carta explicatoria debe adjuntarse en la solicitud, a partir del
1o. de enero de 1987).
b. De los dos bloques de firma, solo debe completarse uno. Olimpíadas Especiales de Illinois trabajan bajo el entendido de que
esta sección puede firmarse, ya sea por:
• El padre (biológico o adoptivo) a menos de que el atleta se la haya designado un guardián por parte del estado;
O POR • El guardián legal; esta persona debe ser asignada legalmente para el individuo;
O POR • El atleta, si él o ella es mayor de 18 años y no ha sido designado como que necesita de ello y que no tuvo que habérsele
asignado un guardián legal. Es necesaria la firma de un testigo, si la firma del atleta es ilegible (por ejemplo, si la firma del
atleta es una “X”).
APROBACIÓN MÉDICA
3. Debe completarse, firmarse y fecharse la sección de la Aprobación Médica por un profesional médico con licencía para administrar exámenes físicos por el estado donde él o ella ejerce. A partir del 1o. de septiembre de 1990, e incluyéndolo, la Solicitud de
Participación en Olimpíadas Especiales será la única forma de consentimiento médico que se aceptará como válida por Olimpíadas
Especiales de Illinois.
Esta persona, al firmar la Aprobación Médica, está declarando que el atleta está en buena salud y que puede participar de manera
segura en los entrenamientos y competenciones de Olimpíadas Especiales. Se aconseja de manera muy especial que la persona que
administra el examen físico posea lo siguiente:
• Formación y conocimientos en dispensar chequeos o exámenes físicos.
• Credenciales para administrar chequeos o exámenes que no comprometan su área de especialidad.
DESPUÉS DE COMPLETAR LA SOLICITUD ...
4. Envíe la copia original de la Solicitud de Participación al Director de Área, quien mandará la solicitud a la oficina de Olimpíadas
Especiales, Capítulo de Illinois. La oficina del Capítulo validará la Solicitud de Participación y mandará de regreso una copia de ésta
con el sello de aprobado a SOAD (Director Deportivo de Olimpíadas Especiales). Una Solicitud de Participación no será validada
sino hasta que toda la información sea correcta y completada en el formulario aprobado.
5. Olimpíadas Especiales de Illinois exige que todas las Solicitudes de Participación se presenten antes de y no después de la fecha
límite establecida para la Solicitud Médica en un evento a nivel de campeonato del Capítulos (las Olimpíadas de Invierno, el Torneo
Estatal de Baloncesto, las Olimpíadas de Verano, el Festival Deportivo en Exteriores, las Olimpíadas de Otoño, las Olimpiadas de
Hockey Sobre Césped y las Olimpiadas de Bowling). Todas las solicitudes para el evento en cuestión deben ser validas una vez
cumplida la competición del Capítulo.
Las Solicitudes de Participación para los atletas que toman parte en los Torneos de Distrito y en los Torneos Seccionales deben
recibirse antes de la fecha límite de entrada o con los materiales de inscripción.
No se aceptarán las solicitudes archivadas o que se reciban por la fecha límite especificada.
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