Kidnetics Summer Basketball Clinic

Kidnetics Hoops Clinic

A basketball clinic for kids and young adults on the autism spectrum.
Camp fees and Details

$350 per hooper. Includes $100 non-refundable administration fee that will be applied toward the cost of the entire clinic. Payments may be paid monthly( $125 a month) or in full. Each session will be 150 minutes in length and will be led a skilled occupational therapist and another support staff. Each session is aimed to have 12 or fewer participants per session to maintain a low camper to staff ratio and ensure personal attention and a positive experience for all participants. Our basketball camp is designed for individuals with sensory processing differences, and is led by a skilled and compassionate occupational therapist who understands their needs and tailors the program accordingly. The clinic is 5 sessions total and runs from July 22-26, Monday to Friday from 10:00am-12:30pm. After registering your child, you will receive an invoice from Kidnetics Pediatric Therapy which you may pay by check, credit card, or through our online system. If paying by check, please mail to: Kidnetics Pediatric Therapy, 1500 Valley House Drive Suite 210, Rohnert Park CA 94928
Athlete Information
Athlete's Name

First NameLast Name
Birth Date

MonthDayYear
Age
Gender

MaleFemaleOther
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information
Name

First NameLast Name
Home Number
Cell Number
E-mail
example@example.com
Emergency Information
Emergency Contact's Name

First NameLast Name
Relationship
Phone Number
Alt. Phone Number
Does the athlete have any allergies, chronic illness, or medical conditions? If yes, please describe.
Is the athlete prescribed an inhaler? If yes, please explain any instructions.
Do you consent photo release

YesNo
Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by Kidnetics Pediatric Therapy during the selected camp. In exchange for the acceptance of said child’s candidacy by Kidnetics Pediatric Therapy, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Kidnetics Pediatric Therapy and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions.

In case of injury to said child, I hereby waive all claims against Kidnetics Pediatric Therapy including all staff, coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all sports activities, including basketball. Some of these injuries include but are not limited to, the risk of fractures, paralysis, or death.

Any controversy or claim arising out of or related to my child(ren)’s participation in this group will be attempted to be settled by a professional mediation service, then by binding arbitration pursuant to the applicable rules of the American Arbitration Association.
Medical Release and Authorization

As Parent and/or Guardian of the named athlete, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination, and immunizations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to Kidnetics Pediatric Therapy and its affiliates including Therapists, Coaches, and other employees to provide the needed emergency treatment prior to the child’s admission to the medical facility.

Release authorized on the dates and/or duration of the registered season.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
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Kidnetics Hoops Clinic

Camp fees and Details

Athlete Information