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 ! ( LOYOLA ! ( ! ( NORWOOD ! ( ! ( ( ! ! ( CHASE WELLES HORNER INDEPENDENCE SHABBONA ! ( KOSCIUSZKO ECKHART ! ( DOUGLAS ! ( ! ( HARRISON ! ( MCGUANE ! ( PIOTROWSKI ! ( ! ( VITTUM ! ( ! ( DAVIS SQUARE GAGE MARQUETTE OWENS ! (! ( BESSEMER MOUNT GREENWOOD ! ( WEST PULLMAN Chicago Park District Department of Planning and Construction As of January 2014 ml ! ( 0 1.5 3 6 Miles MANN ! ( ¸ 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. Special Thanks to our Partners & Sponsors!!
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