Adaptive Wiffle Ball Registration Form

Wiffle Ball Registration Form

Practice takes place in central ABQ in February. For the safety of participants, the dates, times and full address of the practice location will be sent directly to participants. Filling out this form will add you to a text/email list for this specific program.
Athlete Information
Athlete Name*

First NameMiddle NameLast Name
Birth Date*

MonthDayYear
Grade*
Gender*
Has the athlete been seen at Carrie Tingley Hospital within the past 2 years?*
Qualifying Diagnosis*
Ethnicity*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Has the athlete ever participated in Adaptive Sports previously?*

Health History
Does the athlete have range of motion issues? If yes, please describe.*
Does the athlete use any adaptive devices?*
If the athlete uses a wheelchair, please indicate to what extent.*
If the athlete uses a wheelchair, please indicate what type of wheelchair they use.*
If the athlete uses a wheelchair, can they transfer independently?*
Does the athlete have any allergies (environmental, medications, foods, etc.)? If yes, please note the allergy, the method of exposure (airborne, ingestion, etc.), the severity of a reaction and how exposure is treated should it occur.*
Is the athlete prescribed an inhaler, epi-pen or other 'emergency' medication(s)? If yes, please confirm that this medication will be accessible at this program, and that the athlete knows how to use it OR that a guardian staying at the event knows how to administer it to the child.*
Does the athlete have any chronic illness, medical conditions, or participation limitations set by a physician that could impact their participation in this program? If yes, please describe the illnesses, conditions, and limitations.*
Is the athlete currently taking any prescribed medications? Please note that CTHF staff and volunteers are not authorized to administer medications to athletes. This question is intended to collect essential health history information to inform emergency services of any medications the participant is taking. This ensures that appropriate care can be provided in the absence of a legal guardian or caretaker.*

Guardian Information
Guardian Name*

First NameMiddle NameLast Name
Phone Number*
E-mail Address*
example@example.com
Annual Household Income*
Number of Household Members*
Emergency Contact

In the event of an emergency or other urgent situation, every attempt will be made to contact the Guardian listed above. If they cannot be reached, the Emergency Contact listed below will be the next person reached out to.
Emergency Contact Name*

First NameLast Name
Relationship to the Athlete*
Emergency Contact Phone Number*
Please enter a valid phone number.

Consent Forms
Medical Release and Authorization

As the parent and/or legal guardian of the named child, I hereby authorize the staff and volunteers of the Carrie Tingley Hospital Foundation to provide basic medical care, such as first aid or CPR, if the need arises during the child's participation in this program. I understand that staff and volunteers will only administer care for which they have received proper training and certification from a recognized accrediting body.

If the child requires medical treatment beyond basic care, they may only be transported by a legal guardian, an emergency contact, or professional emergency services (e.g., ambulance, life-flight). I acknowledge that staff and volunteers of the Carrie Tingley Hospital Foundation will not transport the child to an urgent care center, emergency room, or any other medical facility.

In the event that emergency medical care is necessary, every reasonable effort will be made to contact the parent/guardian listed on this form. If no response is received, the emergency contact will be notified. If neither the guardian nor the emergency contact can be reached, I understand that the Carrie Tingley Hospital Foundation may contact professional emergency services to transport the child for medical evaluation and treatment.

I acknowledge that all medical expenses incurred as a result of illness or injury during the child's participation in this program are the sole financial responsibility of the child's parent/guardian and/or their health insurance provider. I release and hold harmless the Carrie Tingley Hospital Foundation, its staff, volunteers, and affiliates from any claims, liabilities, or expenses arising from medical care provided in good faith under this authorization.
Informed Consent

I, the undersigned parent and/or legal guardian, hereby give my consent for the named child to participate in all activities organized by the Carrie Tingley Hospital Foundation during the selected program. In consideration of the child's participation, I voluntarily assume all risks and hazards associated with these activities, including but not limited to those occurring during travel to and from program sessions.

I hereby release, indemnify, and hold harmless the Carrie Tingley Hospital Foundation, its officers, agents, representatives, volunteers, and any affiliated entities from any and all liability for injuries, damages, or losses incurred by the child as a result of participation in program activities.

I acknowledge and understand that participation in physical activities, including adaptive sports such as adaptive wiffle ball, carries inherent risks. These risks may include, but are not limited to, sprains, fractures, paralysis, or other serious injuries, including death. I further waive any claims against the Carrie Tingley Hospital Foundation, its staff, volunteers, sponsors, advertisers, and, if applicable, property owners or lessors of program venues.

Photo/Video Waiver

In consideration of the child’s participation at this event, I hereby grant permission to Carrie Tingley Hospital Foundation's staff and affiliates to utilize the child’s appearance, performance and/or voice in published media for the purpose of promotion, reporting or publication related to the organization. I understand that no royalty, fee or any other compensation of any kind shall become payable to me for the organizations use of the child's appearance, likeness, voice, etc. There is no time limit on the validity of this release nor is there any geographic limitation on where these materials may be distributed.
Confirmation

By signing and dating below, I confirm that the information provided on this form is true and accurate to the best of my knowledge. By signing and dating below, I agree to abide by the waivers and releases listed above. I acknowledge that by submitting my electronic signature, it carries the same legal effect as a handwritten signature and is equally binding.
Signature*

Powered by Jotform SignClear
Date Signed*

MonthDayYear
Date
Should be Empty:

Wiffle Ball Registration Form

Athlete Information

Health History

Guardian Information

Emergency Contact

Consent Forms

Confirmation