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Advisory Board

What: One day cycling safety and basic skills clinic for beginners.

Who: Kids ages 6-18 with any disability.

Date: Sunday, September 7, 2008
Swope Park
3:30 - 5:00 pm
Gamestreet
Meyers Blvd & Swope Parkway entrance

Sunday, September 21, 2008
Johnson County
3:30 - 5:00 pm
Location - TBD

Cost: $5/class (scholarships available)

Please bring your bicycle if you own one (bikes will be provided for those who need them).

AbilityCAMP Registration Form

AbilityCAMP:

* required

Method of Payment:

Check (Make payable to NSCD-Kansas City)

Credit Card (Please call 303-293-5711)

Date of Class:

September 7

September 21

I will be bringing my own bike:

Yes

Participant First Name:

Participant Last Name:

Parent/Guardian Name:

Address:

City:

State:

Zip Code:

Phone:

Email Address:

Age:

Date of Birth:

Sex:

Male
Female *

Disabilities:

Seizures:

Yes
No *

Medications:

Wheelchair:

Manual
Power

Sign Language Interpreter?

Yes
No *

Emergency Contact:

Emergency Contact Phone:

AbilityCAMP Participant Waiver of Liability

In consideration of my child (participant) being permitted to participate in the Adapted Cycling AbilityCAMP offered by the National Sports Center for the Disabled, on behalf of my child, myself, and anyone who obtains rights from my child or me, I hereby voluntarily waive, fully release and discharge any of the above mentioned agencies and entities, their directors, officers, employees, agents, insurers, various sponsors and paid and non-paid volunteers from liability for injury, illness, death, damage or loss to participant or participant's property arising out of or in any way related to Participant's activities at the Adapted Cycling AbilityCAMP.

I understand that the staff/volunteers of this camp are not allowed to administer medication or provide personal care such as feeding, toileting, and/or dressing. Anyone needing this type of assistance must make their own arrangements. I have read this form and understand its content and request registration for my child.

Agree:

Yes
No *

Photo Release

I grant permission for Participant's picture to be used in publicity or brochures related to this event.

Agree:

Yes
No *

Participant Name:

Date:

By checking this box, this will act as your digital signature.

I agree

Please print this page out and bring it to the camp with you.

Enter Security Code:

P.O. Box 1290, Winter Park, Colorado 80482 USA phone: 970.726.1540 or 303.316.1540 Fax 970.726.4112
Denver Office: 1801 Bryant St, Ste 1500, Denver, CO 80204 ph: 303.293.5711 fx: 303.293.5448 Email: info@nscd.org

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