2026 Pickleball & Corn hole

Camp PossAbilites is a Recreational Therapeutic Adaptive, and Inclusive Sports, Fitness, and Nutrition 90-minute program and activitivities created by the Christina Sullivan Foundation.

All sports programs and activities for children, youth, and adults with differing abilities are adapted to the athlete/participant's skill level. Buddy volunteers are partnered with our athletes/participants with differing abilities to enhance the experience of providing opportunities to create bonds of trust. This leads to inclusion empathy and compassion the Mission of the Christina Sullivan Foundation.

It's not about the sport. It's so much more. Josephine Sullivan, FOUNDER & CEO

Theraputic Benefits

- Stress Reliever - Builds Self Esteem - Creates Social Bonds - Exercise leads to a healthier lifestyle.

All equipment and supplies are provided.

HIPAA (Protected Medical Privacy Rule)

- Please upload a clear picture of participant. *

Please Upload a picture of you and or your athlete/participant TOGETHER. This will assist staff and buddy volunteers identify families/caregivers.*

Athlete/Participants First and Last Name*

First NameLast Name

Athlete/Participants Age*

Athlete/Participants Date of Birth*

Date

Grade/Graduated*

Relevant Diagnosis: Ex. Down Syndrome, TBI, dyspraxia, hemiplegia, Autism Spectrum Disorder (ASD), etc. *

The health information that you provide is under the protection of the federal Health Insurance Portability and Accountability Act (HIPAA). We can use your health information for purposes of treatment, payment and health care operations. Under HIPAA, you have the right to Request restrictions on how we use or disclose your health information in certain circumstances, including for treatment, payment or health care operations. We do not have to agree to your request unless you request restriction on disclosures to a health plan for purposes of payment or healthcare operations, and the health information relates to an item or service for which you, or another person on your behalf, have assumed full financial responsibility. If we do agree to your restrictions, we will be bound by our agreement except in limited circumstances, such as if there is an emergency.

Allergies:*

Parent/Guardian/Caregiver First and Last Name *

First NameLast Name

Parent Cell Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Parent Email Address*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Employer(s)*

Participant Name*

First NameLast Name

Participant Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Guardian/Caregiver Phone Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Participants Medicare/Medicaid #*

Waiver Program: Community Living Assistance and Support Service (CLASS), Deaf Blind with Multiple Disabilities (DBMD), Home and Community-based Services (HCBS), Medically Dependent Children Program (MDCP), STAR+PLUS Home and Community-based Services (HCBS), Texas Home Living (TxHmL) and Youth Empowerment Services (YES).

Insurance Company:*

Name of Policy Holder:*

Policy Number:*

Insurance Company Phone Number:*

Please enter a valid phone number.Format: (000) 000-0000.

Are you receiving Recreational/Occupational Therapy Services*

Physicians Name:*

Physicians Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Physicians Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Camp PossAbilities Scholarship Application

We want all of our participants to have the opportunity to experience Camp PossAbilities. If necessary, the Christina Sullivan Foundation will offer financial scholarships. Once you've finished this form, we'll reach out to you for more information. You'll need to provide all information on the Intake to receive an application.

WAIVER & RELEASE

CONSENT

As the parent or guardian of the child/ren named above, I consent to my child/ren’s participation in The Christina Sullivan Foundation. I understand that The Christina Sullivan Foundation are program activities, and I agree that I (or another responsible adult whom I approve) will assist and supervise my child/ren. I understand that the organizers of The Christina Sullivan Foundation are not and will not be responsible for supervising my child/ren.

RELEASE AND INDEMNITY

I hereby release, discharge, and covenant not to sue The Christina Sullivan Foundation, the organizers of The Christina Sullivan Foundation, and their directors, officers, employees, agents, volunteers, representatives, owners, members, affiliates, successors, assigns and anyone associated with The Christina Sullivan Foundation (collectively, 'Released Parties'), from all liability to me, my child/ren, my and my child/ren’s personal representatives, assigns, heirs and next of kin, for any and all claims, demands, actions, complaints, suits, losses or damages on account of any injury to me or my child/ren, or in connection with my child/ren’s participation in The Christina Sullivan Foundation, including but not limited to personal injuries or property damage caused or alleged to be caused, in whole or in part, by the negligence of the Released Parties or otherwise.

If, despite this release, I, my child/ren, or my child/ren’s personal representatives, assigns, heirs or next of kin make a claim against any of the Released Parties named above, I agree to indemnify, defend and hold harmless the Released Parties from any litigation expenses, attorney fees, loss, liability, damage, or cost incurred due to such claim.

Furthermore, I agree to release, indemnify, defend and hold harmless the Released Parties from and against any and all claims, demands, actions, complaints, suits, losses, damages or other forms of liability that any of them may sustain arising out of my child/ren’s failure to comply with applicable laws or arising out of any damage or injury caused by me or my child/ren in connection with participation in The Christina Sullivan Foundation.

I HAVE READ THIS PARENTAL CONSENT, UNDERSTAND THAT BY AGREEING I GIVE UP SUBSTANTIAL RIGHTS THAT I AND/OR MY CHILD/REN WOULD OTHERWISE HAVE TO RECOVER DAMAGES FOR LOSSES OCCASIONED BY THE RELEASED PARTIES’ FAULT, AND SIGN IT VOLUNTARILY AND WITHOUT INDUCEMENT. I ALSO CONFIRM THAT I AM THE PARENT OR LEGAL GUARDIAN OF THE CHILD/REN NAMED ABOVE.

PHOTOGRAPHY DISCLAIMER

I hereby grant The Christina Sullivan Foundation permission to make still photographs, video recordings, audio recordings and other recordings of me and/or my child/ren and/or to use my name and/or my child/ren’s name and/or my likeness and/or my child/ren’s likeness and/or verbal quotes from me and/or my child/ren (“Authorized Materials”) and to reproduce and distribute the Authorized Materials in or across any media. I also give The Christina Sullivan Foundation permission to use the completed Authorized Materials, and to use my or my child/ren’s name and likeness for The Christina Sullivan Foundation promotional and commercial purposes without compensation. I waive the right to review materials produced by The Christina Sullivan Foundation, including those using my or my child/ren’s name and likeness.

Furthermore, I relinquish and grant to The Christina Sullivan Foundation all rights, title and interest in and to the Authorized Materials that I and/or my child/ren may have, including but not limited to completed still photographs, video tapes, audio recordings, negatives, prints, reproductions, duplicates and verbal quotes for print. I will not object to or take any adverse action against The Christina Sullivan Foundation for use, reproduction, or distribution of such Authorized Materials.

Signature*

Welcome to Camp PossAbilities!

Adaptive Pickleball and Corn Hole

Information Athlete/Participant Profile

Parent/Guardian/Caregiver Information