PROGRAM GUIDE - WSSRA

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School-Aged “ I value WSSRA programs for Gabby because they keep her moving! WSSRA provides her with excellent care. ” Gabby Resendez’s mom SUPER BOWLERS ALL ABILITIES Enjoy an afternoon of bowling fun! Participants will: • Be taught bowling skills in a progression • Learn techniques • Learn basic scoring Bumpers and adaptive equipment will be available if needed. Door to door transportation is available. Age: 7-22 Years Location: Circle Lanes, Forest Park Time: 3:45-5:15 PM Date: Thursdays, Sept 29 - Nov 17 Fee: $40.00 Trans: $48.40 Registration Number: 427 BERWYN SPORTS GALORE LD, BD, VI, PI Join us after school to have fun and make friends through sports and games. Transportation home is available. Age: 7-14 years Location: Havlicek School, Berwyn Time: 3:00-4:30 PM Date: Wednesdays, Sept 28 - Nov 16 (no program Oct 26) Fee: $16.15 Trans: $24.20 Registration Number: 415 YOU’RE INVITED TO A GOLF “PAR-TEE” FUNDRAISER January 2012 @ White Pines Golf Dome at the White Pines Golf Course 500 W Jefferson St., Bensenville Enjoy 3 hours of golf fun: driving range, swing evaluation, longest drive competition, virtual golf, drinks, refreshments & tips from a pro. Funds raised support WSSRA programs. Check website for updates (wssra.net) Call 847.455.2100 to RSVP. Registration Number: 197 T LEGACY SPORTS ALL ABILITIES WSSRA is teaming up with Legacy Sports in an exciting new program! Start your child off on the right foot in the world of sports with Caleb Fields and Dan Kane, owners of Legacy Sports and skilled athletes. WSSRA will provide the support staff needed for your child’s success. For more information go to legacysportscamp.com Age: 4-8 years Date: Tuesdays, Sept 27 - Nov 22 (no program Nov 8) Time: 3:30-5:00 PM Location: TBA Fee: $45.00 Registration Number: 435 WEDNESDAY EXPLORER’S CLUB HI, DEAF, HARD OF HEARING Join us for an afternoon of fun & games. Participants will have opportunities to: • Be challenged in team building activities • Learn team rules to games and about good sportsmanship • Enjoy expressing themselves through drama and art activities. This program is partially funded by a Town of Cicero grant. Age: 7-22 years Location: Hawthorne Park District, Cicero Time: 3:30-6:00 PM Date: Wednesdays, TBD Fee: $TBD Registration Number: 425 14 WSSRA.NET
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 MEDICAL CLEARANCE Athlete Name (last name, space, first name) SO ILL Rev. 8-1-10 Birthdate M M D D Y Y SO ILL OFFICE ONLY PLEASE CHECK MEDICAL INFORMATION Agency Name Athlete’s Mailing Address Athlete’s City Parent’s/Guardian’s (Please Circle One) Home Address Parent’s/Guardian’s City Sex (M or F) 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 State Zip Code Ethnicity - Parent’s/Guardian’s Home Telephone HEALTH INSURANCE & EMERGENCY INFORMATION (Required for Processing) Person to be contacted in case of emergency White Black/African American Hispanic/Latino Other Medical Insurance Company Asian State Zip Code - - Emergency Contact Phone ( ) Policy Number - Does the athlete have or is the athlete: Heart Problems Yes No Diabetic Yes No Epileptic/Seizures Yes No Blind Yes No Deaf Yes No Hepatitis Yes No Other Current Medication 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 provisions of the above release and/or have had them explained. I hereby agree that I will be bound thereby and I shall defend Special Olympics Illinois and hold it harmless from disaffirmation thereof. Entrant Witness Date Athlete’s Email Address I, THE UNDERSIGNED PARENT AND/OR GUARDIAN of the above specified Entrant, have read and fully understand the provisions of the above release and have explained them to said Entrant. I hereby agree that I and said minor will be bound thereby, and I shall defend Special Olympics Illinois and hold it harmless from any disaffirmation thereof by said minor. Signature of Parent and/or Legal Guardian (Check appropriate box) Print Name Date 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 Phone ( ) Original parent/guardian and doctor signatures are required by the office of Special Olympics Illinois. Faxed signatures will not be accepted.
Page 1 and 2: PROGRAM GUIDE HOLIDAY HULLABALOO PA
Page 3 and 4: WSSRA Staff WSSRA STAFF TO BE ANNOU
Page 5 and 6: Get Involved WSSRA is looking for e
Page 7 and 8: WSSRA Program Policies REGISTRATION
Page 9 and 10: Children MIGHTY MOVERS ALL ABILITIE
Page 11 and 12: School-Aged SWIM LESSONS ALL ABILIT
Page 13: School-Aged EXPLORE THE ARTS ALL AB
Page 17 and 18: Sports & Fitness BOBCATS PRESEASON
Page 19 and 20: Adaptive Sports WHEELCHAIR BASKETBA
Page 21 and 22: Pick Up Point: WSSRA Office, 2915 M
Page 23 and 24: Older Adults WILD CARD WEDNESDAYS H
Page 25 and 26: FALL 2011 REGISTRATION FORM MAIL TO
Page 27 and 28: Special Events RegistratiHOLIDAY HU

PROGRAM GUIDE - WSSRA

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