ASPO Dream Camp 2019 Application
Athlete registration must be completed by an adult 18 years or older by June 22, 2019
Camper First Name *
Your answer
Camper Last Name *
Your answer
Street Address: *
Your answer
City: *
Your answer
State: *
Your answer
Zip Code: *
Your answer
Email: *
Your answer
D.O.B. *
MM
/
DD
/
YYYY
Disability: *
If "other" disability, please list type:
Your answer
Gender *
Race
Shirt Size *
How did you hear about Dream Camp? *
Your answer
Do you plan on participating in ASPO's yearly programs? *
Special accommodations/needs (include any dietary restrictions & allergies): *
Your answer
(if minor please complete the following) Parent/Legal Guardian First Name:
Your answer
Parent/Legal Guardian Last Name:
Your answer
Parent/Legal Guardian Relationship:
Your answer
Parent/Legal Guardian Cell Phone:
Your answer
Parent/Legal Guardian Street Address:
Your answer
Parent/Legal Guardian City:
Your answer
Parent/Legal Guardian State:
Your answer
Parent/Legal Guardian Zip:
Your answer
Parent/Legal Guardian Email:
Your answer
Are you bringing a parent or personal care attendant? *
If yes, Name:
Your answer
Is it necessary for your parent or personal care giver to stay with you? *
If yes, do you need a separate room for you and your parent or personal care giver?
ATHLETE MEDICAL HISTORY: Who do we contact incase of an emergency? *
First and Last Name:
Your answer
Emergency Contact Relationship to Athlete: *
Your answer
Emergency Contact Daytime Phone: *
Your answer
Emergency Contact Evening Phone: *
Your answer
Physician's Name: *
Your answer
Physician's Daytime Phone: *
Your answer
Physician's Evening Phone: *
Your answer
Hospital of Choice: *
Your answer
Have you had (or do you presently have) any of the following? (Please select each one applicable.) *
Required
Have you had a recent tetanus booster? *
If yes, when?
Your answer
Are you currently taking any medications? *
If yes, please list medication name, dosage and reason (list if medication needs refrigerated):
Your answer
Have you had surgery in the last 6 months? *
If yes, please describe:
Your answer
Has the doctor placed any restriction on your activity? *
If restrictions apply, what are they?
Your answer
Are you able to push a manual wheelchair ? *
Do you wish to go Kayaking? (This is one of the activities on Saturday. All Kayaks are adaptive and have been tested before and will not tip over as there are outriggers on them. All participants will be required to wear a life jacket during this time) *
If yes, do you want to Kayak *
Do you need transportation to and from camp?
ASPO PARTICIPANT EXPECTATIONS *
FURTHERMORE, ATHLETES WHO PARTICIPATE IN ASPO PROGRAMS:Will understand and respect the differences between athlete roles and coaching roles and will refrain from coaching other players during games and practices. Uphold the authority of ASPO staff, coaches and officials who are working with you. Assist them when possible and use good judgment if you disagree with them. Will be a positive role model by respecting ASPO staff, officials and their authority during games and will never question, discuss or confront coaches before, during, or immediately after a contest. Will take time to speak to coaches and ASPO staff at an agreed upon time and place. Keep negative comments to yourself. Express concerns only to the coach and in a straightforward, fair, and objective manner. Will try your best to make athletics a positive experience for everyone involved. Will treat other players, coaches, ASPO staff, officials, and spectators with respect regardless of race, creed, color, sex or ability. Will promote the emotional and physical well-being of all athletes ahead of any personal desire you may have to win. Will not encourage any behaviors or practices that would endanger the health and well-being of participants. Will be a positive role model and encourage sportsmanship by showing respect and courtesy, and by demonstrating positive support for all players' coaches, officials, ASPO staff and spectators at every game, practice or sporting event. Will not engage in any kind of unsportsmanlike conduct with any ASPO staff, official, coach, player, or parent such as booing and taunting; refusing to shake hands; or using profane language or gestures. Will remember that your participation in an ASPO athletic event is a privilege and not a right. Will follow ASPO’s drug and alcohol free policies and refrain from use of alcohol and other drugs before or during contests. Will uphold ASPO policies included in the handbook.
Required
ASPO Waiver, Release of Liability, and Consent for Medical Treatment: *
In exchange for my being allowed to participate in the Adaptive Sports Program of Ohio (“ASPO”) activities, programs and/or events, I and if I am not yet 18 years old, my parent or legal guardian, agree to be bound by each of the following: 1. Assumption of Risks: I assume all risks connected with my participation in ASPO’s activities, programs and/or events. I accept personal responsibility for any liability, injury, loss, or damage in any way connected with my participation in ASPO’s activities, programs and/or events. 2. Waiver and Release: I release and discharge ASPO and each of their directors, officers, sponsors, agents, and assigns from all claims for any liability, injury, loss or damage in any way connected with my participation in ASPO’s activities, programs and/or events.. I intend for this waiver and release to also apply to my relatives, personal representatives, heirs, beneficiaries, next of kin, and assigns who might pursue any legal action or claim for such liability, injury, loss or damage. 3. Consent for Medical Treatment: I agree that ASPO may, but have no duty to provide me, through medical personnel of their choice, medical assistance, transportation, and emergency medical services. I have read this Waiver, Release, and Consent and understand and agree to the terms and conditions contained herein. I am signing this Waiver, Release, and Consent voluntarily.
Required
ASPO CODE OF CONDUCT *
Adaptive Sports Program of Ohio (“ASPO”), a non-profit organization, provides quality competitive and non-competitive sports and recreation, which includes establishing a high standard of athlete behavior, and ensuring the safety and well-being of all athletes involved in training and competition. All athletes and participants are expected to abide by the following Athlete Code of Conduct. ATHLETE STANDARDS OF BEHAVIOR The following behavior is unacceptable while participating in any ASPO event, including but not limited to training, program sessions or competitions, transportation to and from practice/sessions, competitions, and any ASPO organized event: Profanity or verbal abuse; Tobacco use in restricted areas; Use of Alcohol in violation of ASPO’s Alcohol Policy, Physical or verbal sexual overtures; Physical abuse; Use of illegal drugs or any unauthorized use of controlled substance; Poor sportsmanship; Violent or disruptive behavior; Any unwelcomed physical contact; Possession of harmful weapons; Behavior, including, but not limited to, harassment, bullying, degrading, intimidating, etc., another participant, staff, spectator, competitor, volunteer or referee in any manner, including, but not limited to, in person, via social media, via electronic communication, via written form etc., which disrupts, impedes or reflects poorly on ASPO. GUIDELINES FOR LIMITING OR DENYING AN ATHLETE INVOLVEMENT: 1) Admission or adjudication of involvement in abuse, neglect, sexual assault or conduct involving violence or threat of violence, 2) Record of being charged with abuse, neglect, conduct involving violence or threat of violence, or sexual assault with corroborating information, 3) Violation of the Code of Conduct, or 4) Use, possession or distribution of illegal drugs. ASPO’s Executive Director and/or Board of Directors will address each situation on a case-by-case basis following the above guidelines. ASPO requires that all athletes understand and sign the code of conduct before participating in ASPO related events and programs.
Required
CONSENT TO PHOTOGRAPH *
Adaptive Sports Program of Ohio is hereby given permission for photographing, recording, and/or illustrating of an individual for release to the news media, promotional, and/or recruiting purposes.
Required
Name of person completing this form: *
First and Last Name
Your answer
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