DiversAbility Day Registration

DiversAbility Day Registration

Please join us Wednesday, July 16th at Interlochen State Park for an exciting day full of accessible recreation! A recreation passport is required for each vehicle attending the event. Completing this registration secures your free meal ticket! Make sure you fill out a registration for each person attending!
Name*

First NameLast Name
Are you coming with an agency? If so, which agency are you affiliated with?
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
County you reside in*
Do you need any accommodations? We will try our hardest to make this event accessible to you with your preferred accommodations. Please describe below and we will reach out to discuss.
Insurance Waiver and Release of Liability

Diversability Day Event
In consideration of being allowed to participate in any way in DiversAbility Day, related events and activities, I and/or participant’s legal guardian, for myself and on behalf of heirs, assigns, personal representatives and next of kin, there undersigned:

1. I agree that prior to participating, I will inspect, or parent and/or legal guardian, will instruct the participant to inspect, the facilities and equipment to be used, and if I believe to the best of my ability that anything is unsafe, I and/or legal guardian will immediately advise DiversAbility Day coordinators of such condition(s) and refuse to participate.
2. Acknowledge and fully understand that I will be engaging in activities that involve risk of serious injury, including permanent disability and death, sand severe social and economic losses which might result only from my own actions, inactions or negligence of others, the rules of play, or the condition of the premises or any equipment used. Further, that there may be other risks not known to me or not reasonably foreseeable at this time.
3. Assume all the forgoing risks and accept personal responsibility for the damages following such injury, permanent disability, or death.
4. Release, waive, discharge and covenant not to sue the Lighthouse Neurological Rehabilitation Center, Department of Natural Resources, Disability Network, Norte, Wheels in Motion, Michigan Assistive Technology Program, Discovery Pier, Michigan Track Chair, Rehab Mobility Systems, their representative administrators, directors, agents, and other employees of the organization, volunteers, other participants, sponsoring agencies, sponsors, advertisers, their heirs, and if applicable, owners, leasers of premises and equipment, all of which hereafter referred to as “releasees”, from demands, losses or damages on account of injury, including death or
damage to property, causes or alleged to be caused in whole or in party by the negligence of the releasees or otherwise
I giver permission for DiversAbility Day coordinators to take my photo/video and to potentially use this photo for marketing, education, or other adaptive sports awareness materials. This authorization expires on the date that is five (5) years after the event date.*

YesNo
I/WE HAVE READ THE ABOVE WAIVER AND RELEASE, UNDERSTAND THAT I/WE HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, HAVE NOT CHANGED IT ORALLY, AND SIGN IT VOLUNTARILY. I/WE UNDERSTAND THAT THE ABOVE APPLIES NOT ONLY TO CLINIC EVENTS BUT ALSO TO PRIVATE LESSONS, AND RENTAL/LOANING OF EQUIPMENT.
Participant Signature:*

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Participant Name:*

First NameLast Name
Date:*

MonthDayYear
PARENT OR LEGAL GUARDIAN
This is to certify that I, as parent/guardian with legal responsibility for this participant, do consent and agree to his/her release as provided above of the Releasees from any and all liabilities incidents to the participant’s involvement or participation in these programs as provided above, EVEN IF ARISING
FROM THEIR NEGLIGENCE
PARENT/GUARDIAN'S SIGNATURE

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Emergency Phone
Please enter a valid phone number.
Date

MonthDayYear
Should be Empty:

DiversAbility Day Registration

Insurance Waiver and Release of Liability