'Volleyball for All' Adaptive Sport Youth Clinic Registration/Waiver Form [March 8, 2014]

1. Adaptive Sports Youth Clinic

 
You have entered a secure online registration system.

In this system you may register for our Adaptive Sports Youth Clinic and MORE IMPORTANTLY complete a Medical and Liability Waiver.

One form PER PARTICIPANT

NOTE: Questions marked with an * require all fields be completed. If a particular question does not apply please enter n/a.
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1. Will you be attending our adaptive sports youth clinic on Saturday, March 8th [3:30-5pm] at the Raleigh Convention Center [500 Salisbury Street, Raleigh, NC]?
*
2. Enter PARTICIPANT'S name:
3. All participants will attend free of charge. Each participant may also designate [4] guests who may also attend free of charge. Please provide us with the names of those you would like added to the guest list:
*
4. Enter PARTICIPANT'S gender:
*
5. PARTICIPANT'S Age:
*
6. PARTICIPANT'S Birthdate:
MM DD YYYY
Birthdate
/
/
*
7. Please enter school information for the PARTICIPANT:
*
8. How did you become aware of this opportunity?
*
9. Will the PARTICIPANT be using an Assistive Device? If so, please indicate:
*
10. All PARTICIPANTS must be able to perform the following tasks [or be accompanied by a 'personal care provider']:

1] Dress and eat without assistance.
2] Perform all aspects of personal hygiene.
*
11. PARTICIPANT'S physical disability [define below]?
*
12. PARTICIPANT'S who are amputees, please indicate location:
13. Health Information for PARTICIPANT [OPTIONAL - this information will only be shared with emergency medical care providers if there was an emergency during the event].
14. Any Additional Notes:
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