Summit Adaptive Sports Club (SASC)

Summit Adaptive Sports Club (SASC)

Registration Form
Participant Details
Child's Name

First NameLast Name
Date of Birth

MonthDayYear
Address

Street Address

Street Address Line 2

SuburbState

Post Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Additional Information
Child's Diagnosis
Does your child have any precautions we should be aware of ?
E.g. Hip subluxation, G-Tube, AFOs for weight bearing etc
Equipment your child will use to participate

Race RunnerGait Trainer / WalkerWheelchairTricycleNil equipment
Does your child need assistance to mobilise with the above equipment?
T-Shirt Size
S/M or 6 etc
Equipment Needs
Is there any equipment you would like to trial from Dejay Medical?
E.g. Race Runner, walker, tricycle etc

What is Summit Adaptive Sports Club?

SASC is a monthly social sports group for kids of all abilities and ages. Run by physiotherapists and assisted by a Dejay Medical rep, kids have the opportunity to participate in weekend social sport, trial new equipment and make new friends while keeping active!
THE DETAILS:

Where: The Ridge Athletics Track, Barden Ridge

When: 9.30am - 11.00am Saturdays, once a month (starting from 1st June 2024)

Cost: $45/session (NDIS Core Supports funding can be used)
GENERAL PROVISIONS

Supervision

Participants will perform all activities under the supervision of the Summit Rehab physiotherapists, Dejay Medical equipment rep and volunteers.

Parent/Guardian(s)

Parent/Guardian(s) of the participants are required to remain present throughout the session and assist where appropriate.

Requirements

The participants should be in good health and have no medical limitations that would cause the activities as described above to be detrimental or dangerous to the child. Parents/guardians should specify any medical problems in the section above.

Indemnification

Parent/Guardians agree to indemnify and defend all physiotherapists from Summit Rehab against all claims, causes of action, damages, judgements, cost or expenses, including attorney fees and other litigation costs, which may arise from the participant, the family’s or carer’s participation or presence, during activities with SASC during the monthly sporting event at Barden Ridge.

Film and Photo Release

I hereby give permission for video, audio and photographs taken of myself and/or the participant during the SASC sessions to be used in any of the following forms: Social media platforms, promotional material, treatments, courses, research purposes and education. I agree that to waiver and release Summit Rehab from any Liability Infringement of my rights and give permission for all Video, Audio and photographs to be utilized. By Signing this release I acknowledge that I have read and understood the above release.
Signature

Clear
Parent/Guardian Name

First NameLast Name
Date Signed

MonthDayYear
Date

Consent
I hereby agree and declare that I am the legal parentguardian of the above-named child and hereby consent to the child's participation in the activities described above. I understand that activities of the kind described above may result in physical injury to my child but nonetheless specifically request that he or she be allowed to participate in those activities.

If the above-named child requires any emergency medical treatment or procedures during the activities, I hereby consent to and authorize the above-named activity supervisor(s) to make any decision and take any action to arrange for such procedures or treatments in the discretion of the activity supervisor(s).

I, the parent/guardian, hereby agree and declare that I have carefully read and understand the general provisions, understand its contents, and agree to its terms and conditions.
Signature

Clear
Parent/Guardian Name

First NameLast Name
Date SIgned

MonthDayYear
Should be Empty:

Summit Adaptive Sports Club (SASC)

Participant Details

Additional Information

Equipment Needs

What is Summit Adaptive Sports Club?

Film and Photo Release

Consent