Tread Setters Registration Form

Qualifying Diagnosis*
Have You Been Seen At Carrie Tingley Hospital Within The Past 2 Years?*
Please List All Medications You're Currently Taking. *Carrie Tingley Hospital Foundation Employees and Volunteers Do Not Administer Medications**
Do You Have Range Of Motion Issues? If so please Describe.*
Do you use any adaptive devices?*
What is Your Wheelchair Usage?*
What is Your Wheelchair Type?*
Do You Transfer Independently? *
Have You Ever Participated In Adaptive Sports Before?*
Do You Have Any Food Allergies? If, so please list below.*

Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by Carrie Tingley Hospital Foundation during the selected camp. In exchange for the acceptance of said child’s candidacy by Carrie Tingley Hospital Foundation, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Carrie Tingley Hospital Foundation 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 Carrie Tingley Hospital Foundation including all 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.
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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Cyclist Information