Self Determination Program

OMG - RC/ SDP/ DOR Registration Form

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Participant's Name:*

First NameLast Name
Birth Date:*

MonthDayYear
Home Phone Number:*

Area CodePhone Number
Mobile Number:

Area CodePhone Number
Email Address:*
Desired Name Tag:*
Primary Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Select Camp shirt size:*

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Please provide any medical or dietary restrictions you have:
How did you hear about Camp?:*

Emergency Contact Information
Emergency Contact Name:*

First NameLast Name
Emergency Contact Phone Number:*

Area CodePhone Number
Relationship to Participant:*

Participant Information
Name:
Age:
School, if any?:
Regional Center?:*
Regional Center Coordinator Name:*
Regional Center Coordinator Email: *
Self Determination Coordinator Name:*
Self Determination Coordinator Email: *
FMS Provider name: *
FMS Provider address: *
What camp will your child be attending?
What camp/ program will participant be attending? (if more than one, you will need a registration form for each camp.)*
Will you require OMG Home Transportation Services?*
Will a personal caregiver/ ABA therapist be attending?
Therapist name:
Currently taking any medications?*
If yes, please list medication(s), dosage and reason for use. Please include any important instructions we should be aware of during camp hours.: *
Allergies (food, medication, environmental):
Mobility Limitations/ Restrictions:
Sensory Considerations:
Communication Preferences (verbal, non-verbal, sign language, AAC device):
Behavioral Considerations and Support Strategies:
Recent surgeries/ hospitalizations:
Physician's Name and Phone:
Requested Start Date:

MonthDayYear
Date
Frequency (weekly, multi-times/ week):
Preferred Session Days/ Times:
Location of sessions:
Length of sessions:
OMG YOUTH SPORTS & OMG ADVENTURE CLUB
COMPREHENSIVE WAIVER, RELEASE OF LIABILITY, ASSUMPTION OF RISK, MEDIA CONSENT & ARBITRATION AGREEMENT

In consideration of my child(ren) being allowed to participate in any and all programs, activities, events, transportation, and services provided or facilitated by OMG Youth Sports and OMG Adventure Club (hereafter “OMG”), I, the undersigned parent or legal guardian, hereby agree to the following terms:

1. Acknowledgment and Assumption of Risks
I understand and acknowledge that participation in sports, enrichment, movement, recreation, transportation, off-site trips, and other activities organized by OMG involves inherent risks, including but not limited to: personal injury, illness (including communicable diseases), property damage, emotional distress, vehicle accidents, negligence by third parties, and unforeseen hazards.

I voluntarily and knowingly assume full responsibility for all risks associated with my child’s participation in OMG activities.

2. Transportation and Third-Party Driver Acknowledgment
I understand that transportation may be provided by OMG staff, volunteers, or third-party drivers or vendors. I acknowledge that OMG does not own or control all vehicles used for transportation and may contract or partner with outside providers.
I agree to release, waive, and hold harmless OMG from any liability, claim, or injury resulting from the actions, omissions, or negligence of any third-party transportation providers or drivers not employed directly by OMG.

3. Waiver and Release of Liability
I, on behalf of myself and my child(ren), hereby release, waive, discharge, and hold harmless OMG, its officers, directors, staff, agents, volunteers, contractors, representatives, insurers, successors, and assigns from any and all claims, causes of action, liabilities, damages, losses, or expenses, known or unknown, arising out of or in connection with participation in any OMG activity — including travel and transportation — whether arising from negligence or otherwise.

This release includes but is not limited to claims for bodily injury, death, property damage, emotional harm, or financial loss.

4. Hold Harmless and Indemnification
I agree to defend, indemnify, and hold harmless OMG and all related parties against any and all claims, lawsuits, losses, liabilities, and expenses (including attorney’s fees) brought by or on behalf of my child(ren), myself, or any third party related to participation in any OMG activity.

5. Emergency Medical Authorization
I authorize OMG personnel to obtain emergency medical treatment for my child(ren) if deemed necessary, and I accept full financial responsibility for any resulting costs.

6. Media Release and Image Consent - Optional (See below)
I hereby grant OMG Youth Sports and OMG Adventure Club the irrevocable right and permission to photograph, video record, or otherwise capture the likeness, image, voice, name, and/or statements of my child(ren) during OMG-related activities, and to use, reuse, publish, and distribute such materials for any lawful purpose, including but not limited to marketing, promotion, advertising, social media, grant reporting, and educational content, without compensation or further consent.

I waive any rights of approval, royalties, or ownership regarding such uses.

7. Code of Conduct and Behavior Policy
I understand that my child(ren)’s continued participation in OMG programs is contingent upon appropriate behavior and adherence to OMG’s Code of Conduct. OMG reserves the right to dismiss any child from a program, without refund, if they engage in behavior that is disruptive, unsafe, harmful to others, or in violation of community rules or safety policies.

8. Consent to Communication
I consent to receive communications from OMG Youth Sports and OMG Adventure Club via email, phone, SMS text, or other electronic means regarding program updates, schedules, opportunities, and reminders.

9. Infectious Disease Acknowledgment
I understand that participation in group activities may include exposure to communicable diseases, including but not limited to COVID-19, influenza, or similar illnesses. I voluntarily assume the risk that my child(ren) may be exposed and waive any claim arising from such exposure.

10. Special Needs and Accommodations
I agree to inform OMG of any medical, behavioral, developmental, or support needs my child may have prior to participation. This includes the need for a personal aide, therapist, or caregiver. I understand that OMG will make reasonable efforts to accommodate needs but cannot guarantee individualized supervision without prior arrangement.

11. Binding Arbitration Agreement
I agree that any dispute, claim, or controversy arising out of or related to this agreement or any aspect of my child’s participation in OMG activities shall be resolved solely by final and binding arbitration, in accordance with the rules of the American Arbitration Association (AAA), and conducted in Los Angeles County, California.

I expressly waive my right to a court trial, including the right to a jury trial or participation in a class action or representative proceeding.

12. Severability and Governing Law
If any provision of this agreement is found to be invalid or unenforceable, the remaining provisions shall remain in full force and effect. This agreement shall be governed by and construed in accordance with the laws of the State of California.

13. Payment & Late Fee Agreement
I agree to pay all fees for the Power of Movement program as outlined in my invoice or service agreement. Payments are due by the agreed-upon date. I understand that late payments will incur a fee of $50 plus 1.5% monthly interest on the outstanding balance. Services may be suspended until payment is made in full.

14. Acknowledgment
I affirm that I have read, understood, and voluntarily agree to this Comprehensive Waiver, Release of Liability, Media Consent, and Arbitration Agreement. I am the legal parent or guardian of the child(ren) listed below and have full authority to execute this agreement on their behalf.
Media release/ image consent:
OMG Youth Sports – Camp Refund & Credit Policy

To ensure the integrity of our programs and maintain fairness for all families and staff, OMG Youth Sports enforces the following refund and credit policy for all camp programs:

No Refunds:
OMG Youth Sports does not issue any refunds for camp registrations under any circumstances.
Camp Credit Policy:

Camp credit may be issued only if requested at least 30 days prior to the camp start date.
Any requests made within 30 days of the camp start date are not eligible for refunds but may be considered for camp credit only, at the discretion of OMG Youth Sports.
After June 1, no refunds will be issued for any summer camp, and only camp credit may be offered, subject to OMG Youth Sports’ approval.
Transfers:

Camp transfers are not permitted unless explicitly approved in writing by OMG Youth Sports.
Unauthorized transfers are strictly prohibited.
Camp Credit Terms:

Camp credit is non-transferable, has no cash value, and must be used within 12 months of the originally scheduled program.
Credit may be applied only to future camps or eligible programs hosted by OMG Youth Sports.
Exceptions:

Exceptions will only be made in the case of medical emergencies with official documentation, and even then, refunds are not guaranteed and will be considered for camp credit only.
By registering for camp, all families agree to the above terms and conditions.

If you have any questions, please contact us at:

📧 Email: omgyouthsports@gmail.com
📞 Phone: (323) 314-8593
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Confidentiality Statement:
All information provided on this registration form is strictly confidential and will be used solely for the purpose of ensuring the safety, well-being, and appropriate support of your child during our programs. We do not share personal or medical information with outside parties without your written consent.

My Products

SDP/ Regional Center Invoice Processing Fee$25.00

One-time non refundable invoice processing fee. Renews in 1 year.

Mandatory Initial Evaluation/ Consultation, ALL PROGRAMS$250.00

Mandatory for all OMG adaptive and Inclusive programs. REFUNDED if covered by Regional Center/ SDP.

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Total $0.00

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OMG - RC/ SDP/ DOR Registration Form

Emergency Contact Information

Participant Information

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