2022 Winter/Spring Program Guide

WINTER/SPRING 2022 PROGRAM GUIDE

January February March April

The McDonough County Special Recreation Association (MCSRA) is a

community therapeutic recreation organization that serves individuals with

disabilities who reside in McDonough County. MCSRA is a legal recreation

cooperative, subject to Section 11-85-14 of the Illinois Municipal Code. Supporting

municipalities include the Macomb Park District, the City of Macomb, and the Village

of Bardolph. It is structured to provide individuals of all ages and ability levels with the opportunity to

enjoy recreational experiences. MCSRA emphasizes recreation, leisure, culture, the environment,

community integration, and family centered activities. Our goal is to provide skills-based programming

to help further develop each individual’s proficiency in specialty areas as well as developing skills for

daily living. One of the aims of the MCSRA is to build a sense of community and support. Through quality

programming such as sporting activities, cooking experiences, travel ventures, outdoor adventures, and

so much more, we provide opportunities for individuals with disabilities to build a social network with

both their peers and caregivers in the McDonough County area.

OUR MISSION

To provide positive, purposeful, and personal recreational experiences for populations with disabilities.

OUR BOARD OF COMMISSIONERS

Board Meetings are held quarterly during the Macomb Park District Board Meetings.

Phil Weiss, Board President

2022 Board Meeting Dates:

Stirling Edwards, Board Vice President

January 18 @ 6:00pm

Russ Hamm, Treasurer

April 19 @ 6:00pm

Emily Gamage, Commissioner

July 19 @ 6:00pm

Molly Selders, Commissioner

October 18 @ 6:00pm

Rachel Lenz, Secretary

309-833-4562 • 1406 N. RANDOLPH ST. • MACOMB, IL

Out with the old,

in with the new!

Before we say goodbye

to the old logo, coming

soon you’ll have a chance

to purchase your Special

Olympics jersey!

The new jersey color may

change, but we will remain

Bulldogs!

Follow Our Social Media to keep updated!

@themcsra

@mcsra

Plan Ahead!

Upcoming Swag

Sale featuring our

new logo and colors!

Sale Date to be Announced

LEISURE INTEREST SURVEY

Please use the scale below to respond to the following statements.

Always True = 3 Sometimes True = 2 Never True = 1

1. I like to read in my free time.

2. I like to be outside instead of inside.

3. I like to create things with wood or metal.

4. I like to be creative in my free time.

5. I enjoy the arts (music, dance, art, poetry, food).

6. I like competitive physical activities (bags, horseshoes, capture the flag).

7. I like talking to and meeting new people.

8. I enjoy being outdoors.

9. I like to do crafts in my free time.

10. I like to go to plays, concerts or visit museums.

11. I like to volunteer at an agency.

12. I like high energy activities.

This is an informal LIM

assessment created by

WIU RPTA 351 Students

to help assist MCSRA on

April 3, 2019.

13. I like outdoor activities.

14. I like to watch community events (parades, fairs, movies in the park).

15. I like to play outside games instead of inside games.

16. I like to work with technology in my free time (iPad, computer games, etc.).

17. I like trying new activities.

18. I like to help others in my free time (grandparents, family, friends).

19. I like to be challenged when playing sports (basketball, soccer, softball).

20. I like activities where I can make new friends.

Please comment any additional suggestions for new activities you would like to see provided:

BECOME A

IRTUALLY NVOLVED

IN EVERYTHING ASS

You can purchase this pass for $40.00 a month to attend any program

you would like – supplies and fun are incuded! You have to purchase the

pass and then register for the programs.

To register for the pass, please contact Julie Eggleston directly.

*OFFER DOES NOT INCLUDE SPECIAL OLYMPICS*

ONLY

$

40

PER MONTH

PROGRAM KEY

COST ASSOCIATED

IN-PERSON PROGRAM

LET’S GET OUT OF TOWN!

DEADLINE TO REGISTER

AND PAYMENT DUE: March 4

Let’s go shopping! Travel with us to the Peoria

shops at Grand Prairie mall and enjoy a lunch at

a local restaurant. This price includes

transportation to the mall and staffing. Please

bring your own money for purchases as well as

approximately $10.00 - $15.00 for lunch.

LOCATION: Macomb Park District Office

R

NR

VIRTUAL PROGRAM

RESIDENT

NON-RESIDENT

FACEBOOK ACCOUNT

REQUIRED

MIN/MAX: 3/5

GOALS: This program is designed to assist the

participants to improve their socialization skills,

increase their leisure education, and increase

their interaction with peers.

DATE DAY TIME FEE

March 12 Saturday 9:00AM-5:00PM

$

30 - R

$

35 - NR

In concern with the health and wellness of our community

that we serve, if McDonough County reports concerning

COVID-19 positivity rates, this program will be cancelled and

a credit will be issued to the participant's account.

PLEASE READ BELOW BEFORE REGISTERING

Due to the ever changing health and safety conditions surrounding COVID-19 and our concern for the community

that we serve, the program plans may be altered or cancelled. You will be informed if an alternative program plan

will take place and you have your choice to attend or to not attend and receive a credit. Please contact Julie

Eggleston, MCSRA Program Supervisor, with any questions that you may have regarding this statement.

PROGRAMS AT A GLANCE

SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY

No programs

Virtual

Microwave

Cooking

Bowling

Buddies

Wednesday

Fundays No programs

Friday

Nights Out No programs

6:00-7:30PM

2:00-3:00PM

6:00-8:00PM

YOUR HOME

4:30-5:30PM

DIGGER’ S BOWL

YOUR HOME

LOCATIONS VARY

In regards to programs that meet on a regular basis, you MUST register for all of the dates listed.

BOWLING BUDDIES

Come bowl at Digger’s Bowl with us every

Tuesday and have fun trying to get a turkey!

Everyone is a winner in this fun program

LOCATION: Digger’s College City Bowl

MIN/MAX: 5/30



improve their gross motor skills, and increase

their interaction with peers.

DATES DAY TIME FEE

SESSION 1

January 25 -

$

45 - R

Tuesday 4:30-5:30PM

March 1

$

50 - NR

SESSION 2

March 8 -

April 26

No programs on

3/15, 4/5

DEADLINE TO REGISTER AND PAYMENT DUE:

Session 1: January 18, Session 2: March 1

Tuesday

4:30-5:30PM

$

45 - R

$

50 - NR

FRIDAY FUN NIGHTS OUT

KINDNESS PARTY

Every first Friday of the month come have fun with the

group out and about around Macomb to enjoy the night!

Enjoy socializing, showing off your dance moves,

celebrating Valentine’s Day and being kind to

each other. Once registered, you will be sent the

link if you chose to be virtual. The scheduled

activities include a karaoke, making a craft,

talking with your friends, and a lot of laughs!

LOCATION: Veterans Park

MIN/MAX: 3/8

DEADLINE TO REGISTER AND

PAYMENT DUE: January 28


participants to improve their socialization skills

and increase their interaction with peers.

DATE DAY TIME FEE

February 4 Friday 6:00-8:00PM

$

10 - R

$

14 - NR

VIRTUAL MICROWAVE COOKING

Join us virtually with the WIU Dietetics

Department students showcasing how to cook

some easy and nutritious microwave meals!

Each session you will receive the ingredients, an

easy to follow recipe and the zoom link to

follow along the instructions and create your

delicious meal.

LOCATION: Your own kitchen!

MIN/MAX: 5/10


PAYMENT DUE: January 31



and to implement healthy eating options.

FEE

WEDNESDAY FUNDAYS

Chat with your friends virtually and have fun

socializing and meeting new people! Activites

include a dance party, playing bingo, karaoke,

yoga, and most importantly, having fun!

LOCATION: Your home

MIN/MAX: 3/30

DEADLINE TO REGISTER AND PAYMENT DUE:

Session 1: February 18, Session 2: April 6




DATES DAY TIME FEE

SESSION 1

February 26 -

$

40 - R

Wednesday 2:00-3:00PM

March 30

$

45 - NR

DATES DAY TIME FEE

February 7-28 Monday 6:00-7:30PM

$

40 - R

$

45 - NR

SESSION 2

April 13 -

May 18

Wednesday

2:00-3:00PM

$

40 - R

$

45 - NR

That’s only $ 5.00 per session―what a deal!


MOVIE NIGHT


PAYMENT DUE: February 25


GAME AND TRIVIA NIGHT


PAYMENT DUE: March 25



Lets watch a movie and check out the new

releases! Registration fee includes admission to

the movie of the participants’ vote. Please bring

extra money for other refreshments.

LOCATION: Rialto Cinemas

MIN/MAX: 3/8




Pick up time will be customized for the end of the movie.



Meet at the Macomb Park District office and join

your friends and have fun playing Bingo for

prizes, guessing your favorite Disney Character

Trivia, and playing Uno Attack.

LOCATION: Macomb Park District Office

MIN/MAX: 3/8



and increase their interaction with peers. This

program is also available virtually so that

everyone can socialize in their comfort zone.

DATE DAY TIME FEE

March 4 Friday 6:00-TBD

$

10 - R

$

14 - NR

DATE DAY TIME FEE

April 1 Friday 6:00-8:00PM

$

10 - R

$

14 - NR


‘WELCOME TO SUMMER’ COOKOUT


PAYMENT DUE: April 29



Join your friends for a fun cook out, music, and

outdoor games to celebrate the upcoming

summer season! While registering, please alert

Julie of food allergies or sensitivities needed.

LOCATION: Glenwood Stone Shelter

MIN/MAX: 3/8




DATE DAY TIME FEE

May 6 Friday 6:00-8:00PM

$

10 - R

$

14 - NR

MARJORIE CONNOR

SPIRIT AWARD 2021

Congratulations to the 2021 Recipient:

MARSHALL WOODSIDE

Thank you to the Connor Family for the ongoing

support of the MCSRA!

Illinois

ATHLETICS

If interested in participating in any Special Olympics sports program, you MUST have ALL

paperwork returned to the MCSRA office by the deadlines. No walk-in registrations will be accepted.

Upon arrival, all athletes much check in with the Program Leader to get your

temperature taken and answer the questionnaire. All athletes must wear a mask while

practicing and withing 6 feet of another athlete while not participating. Hand

sanitizer will be provided for athletes to use before the entrance into the practice and

games and after the practice and games are complete. No eating or sharing drinks will

be allowed during practice.

ATHLETICS (TRACK AND FIELD)

DEADLINE TO REGISTER

AND PAYMENT DUE: March 1

Dig out your running shoes, stretch out your muscles,

and be ready to run! Track and Field starts Sunday,

March 20th! Not much of a runner? No problem we

have events for everyone – running, walking, softball

throw. Come join the team!

LOCATION: Macomb High School Track

MIN/MAX: 5/30



improve their gross motor skills, and increase their

interaction with peers.

DATES DAY TIME FEE

March 20 -

May 1

Sunday

1:00-2:00PM

$

30 - R

$

35 - NR

M A C O M B

BULLDOGS

Do you have all

of your forms

completed?

Use the checklist

to be sure!

Fee includes practice until Regional competition (May 7,

2022). If athlete advances to State competition, there will

be an additional $30.00 fee to cover additional practices.

2022 FORM CHECKLIST

Athlete Consent Form

(2 pages)

Athlete Medical Form

(4 pages)

COVID-19 Code of Conduct

(2 pages)

Forms can be picked up in person at our office

or contact Julie at sra@macombparks.com to

receive the forms via email.

PROGRAM REGISTRATION

This form must be completed signed, and returned with payment to the McDonough County Special Recreation

Association before the participant will be allowed to attend any program. No phone or faxed registrations will be

accepted. Registration forms can be turned in, in person or by mail (1406 N. Randolph St. Macomb, IL 61455). The office

is open Monday-Friday from 8:00am - 4:00pm (aside from holidays).

PROGRAM NAME (OR PROJECT)

FEE

Please attach or list below any updated information we should be aware of:

(i.e. allergies, medications, etc.)

TOTAL FEES DUE: $

Don’t forget to sign and submit your waiver on the other side! It speeds up registration :)

WAIVER, RELEASE OF ALL CLAIMS, AND HOLD HARMLESS AGREEMENT

FORM FOR MCDONOUGH COUNTY SPECIAL RECREATION ASSOCIATION

(MCSRA)

PLEASE

REVIEW

AND SIGN

IMPORTANT INFORMATION

The McDonough County Special Recreation Association (MCSRA) is committed to conducting its recreation programs and

activities in a safe manner and hold the safety of participants in high regard. The MCSRA continually strives to reduce such risks

and insists that all participants follow safety rules and instructions that are designed to protect the participants’ safety. However,

participants and parents’ guardians of minors registering for this program/activity must recognize that there is an inherent risk of

injury when choosing to participate in recreational activities.

You are solely responsible for determining if you or your minor child/ward are physically fit and/or skilled for the activities

contemplated by this agreement. It is always advisable, especially if the participant is pregnant, disabled, in any way or recently

suffered an illness, injury or impairment, to consult a physician before undertaking any physical activity.

WARNING OF RISK

Recreational activities/programs are intended to challenge and engage the physical, mental, and emotional resources of each

participant. Despite careful and proper preparation, instruction, medical advice, conditioning, and equipment, there is still a risk

of serious injury when participating in and recreational activity/program. Understandably, not all hazards and dangers can be

foreseen. Depending on the activity, participants must understand that certain risks, dangers, and injuries due to inclement

weather, slipping, falling, poor skill level or conditioning, carelessness, horseplay, unsportsmanlike conduct, premises defects,

inadequate of defective equipment, inadequate supervision, instruction or officiating, and all other circumstances inherent to

indoor and outdoor recreational activities/programs exist. Participants must understand that certain risks, dangers, and injuries

due to acts of God, inclement weather, slipping, falling, equipment failure, in supervision, premises defects, and all other

circumstances inherent to recreational activities/programs exist. In this regard, it must be recognized that it is impossible for the

MCSRA to guarantee absolute safety.

WAIVER AND RELEASE OF ALL CLAIMS AND ASSUMPTION OF RISK

Please read this form carefully and be aware that in signing it and participating in the MCSRA programs, you will be expressly

assuming the risk and legal liability and waiving and releasing all claims for injuries, damages, or losses which you or your minor

child/ward might sustain as a result of participating in any and all activities connected with and associated with this program/

activity (including transportation services/vehicle operation, when provided).

I recognize and acknowledge that there are certain risks of physical injury to participants in this program/activity, and I

voluntarily agree to assume that full risk of any and all injuries, damages or loss, regardless of severity, that my minor child/ward

of I may sustain as a result of said participation. I further agree to waive and relinquish all claims I or my child/ward may have

(or accrue to me or my child/ward) as a result of participating in this program/activity against the MCSRA, including its officials,

agents, volunteers and employees (hereinafter collectively referred as “MCSRA”).

I do hereby fully release and forever discharge the MCSRA from any and all claims for injuries, damages, or losses that my

minor child/ward or I may have or which may accrue to me or my minor child/ward and arising out of, connected with, or in any

way associated with this program/activity.

I understand the MCSRA may photograph/videotape the events or activity in which I am (or my child/ward is) participating. I

give my permission for the MCSRA to sue photographs or videotape of me (or my child/ward) for the purpose of promoting the

MCSRA and its services/programs. I give my permission with the following understanding: No compensation of any kind will be

paid to me (or my child/ward) at this time or in the future for the use of my (or my child/ward’s) likeness.

If extenuating circumstances prohibit the use of my (or my child/ward’s) likeness, please circle the following:

No Photo

In the event of an emergency, I understand and authorize MCSRA staff and officials to secure from any licensed hospital,

physician, and/or medical personnel and treatment deemed necessary for immediate care for myself or minor child/ward and

agree that I will be responsible for payment or any and all medical services rendered.

I have read and fully understand the above Important Information, Warning of Risk and Release of All Claims and

Assumption of Risk. If registering a minor participant, I further attest that I have read the above to my minor child/

ward.

Participant Name:

Today’s Date:

Participant Signature:

(if 18 years or older)

or

Parent/Guardian Signature:

This form expires one year from date above.

PARTICIPANT ASSESSMENT

Please complete both sides of this form and return to the MCSRA Program Supervisor.

PLEASE

REVIEW

AND SIGN

PARTICIPANT INFORMATION

Participant Name:

Date of Birth:

Gender:

Male

Female

Primary Diagnosis:

Secondary Diagnosis:

Is the participant subject to seizures?

Yes

No

If yes, please complete and return attached seizure questionnaire form.

If diagnosis is Down Syndrome, has the participant been tested for Atlanto-Axial Instability?

Yes

No

If yes, what were the results?

Positive

Negative

Does the participant have a shunt?

Yes

No

If yes, please describe:

Does the participant have a specific diet, dietary restrictions, or any food that may cause behavioral changes?

If yes, please explain:

Yes

No

Does the participant have allergies?

Yes No If yes, please list:

Are there any side effects from the participant’s medications that we should be aware of?

If yes, please explain:

Yes

No

REASONS FOR PARTICIPATING

Please select any/all that apply.

Physical Activity

Socialization/Friends

Exposure

Responsibility

Skill Development

Motor Development

Group Interaction

Creativity

Entertainment

FUN

Specific goals parents/guardians would like to see worked on:

DAILY LIVING SKILLS

Eating Can eat independently Needs to be monitored Needs physical assistance

Bathroom

Can toilet independently Needs to be monitored Needs physical assistance

Detailed comments:

Mobility

Does the participant use any devices for mobility?

Yes

No

If yes, please list:

Specific needs staff should be aware of?

Endurance Balance Gait Other

Explain:

PARTICIPANT ASSESSMENT

Please complete both sides of this form and return to the MCSRA Program Supervisor.

PLEASE

REVIEW

AND SIGN

COMMUNICATION

Speaks Clearly

Speech is difficult to understand

Difficulty expressing needs

Gestures/Pointing

Uses sign language

Uses Hearing Devices

Uses a communication board/pictures

English as a second language

Other:

First language:

INTERACTION/SOCIALIZATION SKILLS

Initiates socialization?

Initiates social interaction on own

Socializes with verbal prompting

Avoids social interactions

Prefers being

Alone

With Peers

With Adults

Detailed comments:

Is most successful in

Large Groups

Small Groups

Other

Responds better to

Males

Females

Either

Following directions

Can independently With verbal prompting With step-by-step assistance

BEHAVIORS/CONDUCT

Short attention span

Hyperactivity

Oppositional/defiant

Steals

Verbal outbursts

Easily Distracted

Runs/wanders

Manipulative

Tantrums

Instigates behavior

Emotional Meltdown Shy/Withdrawn Physical outbursts towards others/self

Other:

What are the known triggers?

Does the participant respond to specific behavior techniques?

Any unusual fears or concerns?

Does the participant respond to specific reinforcement devices?

JUST A FEW MORE THINGS

School/Work:

Grade:

Teacher/Para:

School/Work #:

Parent/Guardian Name:

Email:

Classroom Setting:

Primary Phone:

Address:

PARENT/GUARDIAN SIGNATURE

DATE

COVID-19 ASSESSMENT

Please review the following polices and return the signed form to our office.

PLEASE

REVIEW

AND SIGN

The COVID-19 virus is an extremely contagious virus that spreads easily through

person-to-person contact. Federal authorities and the State of Illinois recommend social distancing to

prevent the spread of COVID-19. Contracting COVID-19 can lead to severe illness, personal injury,

permanent disability, and death. Participation in MCSRA programs could increase the risk of you or your

participant in contracting COVID-19. MCSRA and its staff undertakes every effort to keep the

programming spaces clean and disinfected; however as with any public facility, MCSRA cannot guarantee

that the participant will be 100% safe from airborne illnesses such as COVID-19, colds, or flu while

participating in programs. The MCSRA staff are asking that all participating in programs go through an

assessment with an MCSRA staff member prior to starting programs to ensure the participant can adhere

to Center for Disease Control (CDC) and social distancing guidelines.

Participants will be asked to demonstrate the following during an assessment:

Participant needs to show they can wear a mask independently for an extended amount of time, staff

may assist with tying of masks as needed. The MCSRA staff will conduct and assessment through a Zoom

call or complete a personal assessment to decipher that the participant can successfully wear their

personal mask for the following recommended guideline time frames:

• Early childhood, 10 to 15 minute increments • School age, 10 to 20 minute increments

• Adult, 20 to 30 minute increments

During the assessment period, the MCSRA participants will also need to show the following:

1. Participants can wash their hands independently

or with minimal assistance and/or verbal cue or

prompts.

2. Participants understand not being able to

touch others and keeping distance from others

with verbal cues and prompts.

3. Participants must be able to refrain

from habits that could increase the

spread of illness such as:

• Picking Skin

• Picking nose

• Wiping nose and eyes with hands

• Spitting

• Putting objects in their mouth

4. Participants must allow a visual

health screening upon arrival and

departure. Employees will look for

the following during a visual

health screening:

• No soiled clothes

• No open wounds

• No visual symptoms of illness

5. Participants must be

able to use the

bathroom with minimal

assistance. MCSRA

staff will not be

allowed to assist with

toileting or transferring

at this time.

As part of the registration process participants and/or care givers are committing to following

guidelines set forth by CDC and the Illinois Department Public Heath (IDPH).

• Participant has no temperature (lower than 100.4°)

• Participant is free of shortness of breath

• Participant is free of diarrhea

• Participant is free of cough

• Participant is free of sore throat

By signing registration form for programs, program participant and/or guardians are agreeing to check the

participant’s temperature prior to programs ensuring it does not exceed 100.4 F. If temperature exceeds 100.4 F,

participants will not be allowed to attend programs that day. This is to ensure the safety of participants and employees.

I, as the guardian or self, understand the above statments and agree to them.

Participant Name:

Today’s Date:




SEIZURE QUESTIONNAIRE

If a participant has been diagnosed with a seizure disorder, epilepsy, or experiences episodes of

seizure activity, a completed Seizure Questionnaire, or equivalent seizure plan is required for

participation in MCSRA programs The document is kept on file and a copy is given to program staff in

order to provide the desired level of care in the event of a seizure during the program.

PLEASE

REVIEW

AND SIGN

Please complete this form if the participant experiences seizures, or (if applicable) return a copy of your child’s seizure plan from their school.

PARTICIPANT INFORMATION

Today’s Date:

Participant Name:

Parent/Guardian:

Emergency Contact:

Primary Phone #:

CURRENT SEIZURE MEDICATIONS

Medication:

Dosage:

Time(s) of intake:

PLEASE NOTE:

MCSRA Staff

will not

administer

medication.

SEIZURE TYPE

Please select any/all that apply.

Absence (Staring Spell)

Simple Partial

Generalized (Gran Mal)

Other (explain):

Atonic (drop)

Complex Partial

Date of last seizure:

Average duration?

Duration of longest seizure:

Symptoms prior to the onset of the seizure? (i.e. smells, stomach pain, fear, sounds)

Please list the necessary steps you would like MCSRA to take in the event of a seizure:

1. Call 911 for a seizure lasting more than ___ minutes.

2.

3.

PARENT/GUARDIAN SIGNATURE

DATE

Please note, if this form or other seizure plan is not submitted to MCSRA, staff will call 911 for any seizures lasting longer than 60 seconds.

MCSRA PROGRAM POLICIES

Please review the following polices and return the signed form to our office.

PLEASE

REVIEW

AND SIGN

Parents/guardians and participants are responsible

for informing the MCSRA staff of any changes to

address, phone numbers, or medical information.

If a participant will be absent from a program for

any reason, please notify the MCSRA office one

week (five business days) prior to the program date.

If a participant cancels less than five business days

before the program, only a 50% refund will be

issued. If a participant cancels on the day of the

program, no refund will be issued.

Programs may be cancelled due to inclement

weather or low enrollment numbers. When a

program is cancelled for either reason, a credit will

be placed on the participants account to be used

toward future programs

MCSRA provides an approximate 1:4

staff-to-participant ratio. If the participant requires

a closer 1:1 ratio, please indicate the reason on the

registration form.

Although the MCSRA realizes that inappropriate

behavior may occur in programs, the MCSRA

Director retains the right to suspend participation if

hazardous, disruptive, or destructive behavior

persists. Participants may be held liable for

deliberate destruction of equipment or facilities.

When arriving at or departing from a program,

please check in with the staff before you leave or

take the participant. If someone other than the

parent/guardian will be picking a participant up, a

note must be given to an MCSRA staff member. Staff

will not allow a participant to leave with another

person without written notice.

If a non-authorized individual takes a

child without the consent of the MCSRA, local law

authorities will be contacted and further action will be

taken.

If a participant arrives at a program earlier than 15

minutes prior to the program start time or is picked up 15

minutes later than a program end time, appropriate

parties will be charged for the additional staff expense

accrued during that time.

While MCSRA staff will assist participants with their

belongings at programs, the MCSRA cannot be held

responsible for lost or stolen property. Participants should

not bring valuables to programs.

Consumption of alcohol is not permitted at any MCSRA

program (this includes adults, ages 21 and older).

It is the parent/guardian and participant’s responsibility to

inform MCSRA staff of any medication a participant is

taking. This information is very important in case of an

emergency. Medication information should be noted on

the registration form. Any change in medication should be

communicated to the MCSRA.

For the protection of all participants in programs,

participants must stay home or will be sent home

if he or she shows any of the following symptoms:

• A temperature over 100.4º

• Stomachache accompanied

by diarrhea or vomiting

• Any undiagnosed rash

• Sore or discharging

eyes or ears

• Profuse nasal discharge

(green or yellow)

• Have a highly

contagious condition

such as chicken pox,

measles, lice, etc.

By signing below, you agree to abide by the policies set forth by the MCSRA.

Participant Name:

Today’s Date:



or


This form expires one year from date above.

1406 N. Randolph Street

Macomb, IL 61455

Phone: (309) 833 - 4562

Fax: (309) 836 - 7095

Julie Eggleston

MCSRA Program Supervisor

Sharon Larson

Program Assistant

Efoe Kossi

Volunteer Administrative Assistant

STAFF

WIU RPTA Students

Program Volunteers

2022 Winter/Spring Program Guide

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