SPECIALIZED NEEDS RECREATION

 REGISTRATION FORM

Last Name: _______________________  First: _______________________ Middle: __________________

Address: ___________ Street/PO Box: ________________________  

City: ___________________ State: ____  Zip: _________ 

Phone: ___________________ Email: ____________________________ Date of Birth: ________________ 

Parent/Guardian/Care Provider: _________________________________ Phone: ______________

Emergency Contact Person: __________________________________ Phone: _______________

 

    Applicant's place of residence:

 

Disability (please be specific): _______________________________________________________________

 

    Please check all that apply:                                                                  Explain below:

 

Dietary Precautions: ____________________________________________________________________

 

Medications: __________________________________________________________________________

 

              If yes please include a medication information and waiver form.

 

Activity limitations/Physical problems (if any) ________________________________________________

 

Adaptive equipment (if any) ______________________________________________________________

 

Behavior problems (if any) _______________________________________________________________

Please attach additional information to help assist us should a behavioral problem occur.

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SPECIALIZED NEEDS RECREATION REGISTRATION FORM AGREEMENT STATEMENT:

I am aware that participation in recreational activities may have hazards both obvious and latent which may be caused by my own actions or inactions, by the actions of others participating in the event, or by conditions in which the events take place. I fully accept and assume all such risks and all responsibility for losses, cost, and/or damages I (and/or my minor child‘s) may incur as a result of my (and/or my minor child’s) participation. I also understand that Specialized Needs Recreation has no medical insurance to cover medical expenses and all medical costs are my responsibility.

  

I hereby release, discharges and hold harmless Specialized Needs Recreation, Coeur d’Alene Recreation Department, Coeur d’Alene School Districts, all staff, directors, administration, and volunteers from participation in any recreation programs sponsored by Specialized Needs Recreation. I also release, discharge and hold harmless, any person transporting me (or my child) before, after, and during the activities.

 

If during my (or my minor child’s) participation in Specialized Needs Recreation activities I (and/or my minor child’s) should need emergency medical treatment and I (and/or my minor child’s) am (are/is) not able to give my consent or make my own arrangement for that treatment, I authorize Specialized Needs Recreation to take whatever measures are necessary to protect my (and/or my minor child’s) health and well being, including if necessary, hospitalization.

 

I also give permission for pictures and/or videos of my child and I to be used by Specialized Needs Recreation and any other group they approve for public relations purposes.

 

I have read this “Release of Waiver and Liability, Assumption of Risk, and indemnity Agreement” and fully understand it.

 

Signature of Participant or Parent/Guardian: ___________________________________________

 

Date: ____________________

 

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Human Rights of Persons Served Policy

Each guest and employee of Specialized Needs Recreation will be assured the following rights:

 

1. Humane care and treatment.

2. Will not be put into isolation unattended.

3. Be free of restraint (chemical, mechanical and physical) unless necessary for the safety of others.

4. Be free of mental and physical abuse.

5. To voice grievances and to recommend changes in policies and or services available or charges

     for services.

6. To have access to emergency medical services.  (At my own expense)

7. To refuse optional services.

8. To exercise all their civil rights unless limited by court order.

9. To be treated in a courteous manner.

10. To privacy and confidentiality.

11. To receive services which enhance the guest’s social image and personal competencies, and to

       promote inclusion in the community.

12. To refuse to perform services for the agency.

13. To be protected from harm.  There will be policies and procedures which will insure that all

      confirmed or suspected incidents of mistreatment, neglect, exploitation or abuse of guests are

      reported to the Department of Health and Welfare and to Adult Protective Services within

      48 hours.

14. To be treated as legally competent unless determined otherwise by a court of law.

 

 

If you believe any of your rights have been violated, please contact the Specialized Needs Recreation Director who will provide you with a method to have your complaint reviewed.

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By my signature below, I affirm I have read or have had explained to me all of my Human Rights as a guest of Specialized Needs Recreation and understand my rights.  My signature also confirms that I have had a chance to discuss each right, and if I did not understand my rights, my parent/guardian has reviewed them in detail.

 

___________________________________________                    ______________________________

 Signature                                                                                            Date

___________________________________________                    ______________________________

 Parent/Guardian Signature                                                                  Date