October 2026 Activities Registration Form

Participant's Full Name

First NameLast Name

Participant's Date of Birth

Date

Participant's Email Address, if applicable.

example@example.com

Participant's Phone Number, if applicable.

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

Fitness Group - Tuesdays and Fridays in October, 2:30pm at Medina Planet Fitness. This is a self-lead activity, with authentic opportunities to socialize with group members.

Movie Club - Forgotten Island - October 4 at 3pm, Medina Regal Cinema

Total number attending Forgotten Island, INCLUDING group participant. Enter 0 if not attending

KICKBALL (October and November) - Oct 5, 12 and 26 - The Salvation Army, 425 West Liberty St., Medina. If attending, CHOOSE YOUR SESSION:

Art Group - October 7 at 6pm, Medina County Board of DD

Medina Homecoming Parade - October 8 at 5:30pm - Join us as we wear our Halloween Costumes and ride in a parade float! We meet at 5:30pm on Smith Rd., across from Garfield School.

Hayride - October 15 at 5:30pm - Richardson Farms, 6984 Lafayette Rd, Medina

Total number attending the Hayride, INCLUDING group participant. Enter 0 if not attending

Self Advocacy Group Health and Wellness Series - LIMITED SEATING - Low Impact Exercise - Join us as we discuss the benefits of low impact exercise, and practice a round with our instructor! - October 17 at 3pm, the Medina Recreation Center, 855 Weymouth Rd, Medina

If the Self Advocacy Group is full, would you like to be on the waiting list?

Replay for Kids 5K/1mile - October 18 at 9am (Also, search for race link, sign up, email receipt to Lisa Morrison at info@ics-oh.org for reimbursement.)

Dinner Club - LIMITED SEATING - October 19 at 5:30pm, Winking Lizard, 3634 Center Rd., Brunswick

If Dinner Club is full, would you like to be on the waiting list?

Volunteer Activity: Join us as we come together to meet a pressing need in our community! We are making PB&J Sandwiches for those in need - October 21 at 6pm, Buehler's Community Room, 3626 Medina Rd., Medina

Paws for the Cause 5K/1mile - October 24 at 9am (Also, search for race link, sign up, email receipt to Lisa Morrison at info@ics-oh.org for reimbursement.)

Movie Club - Street Fighter 2026 - October 25 at 3pm, Medina Regal Cinema

Total number attending Street Fighter 2026, INCLUDING group participant. Enter 0 if not attending

Art Group - October 28 at 6pm, Medina County Board of DD

Please select your authority to sign this form:

Integrated Community Solutions, Inc.

Waiver, Release and Hold Harmless Agreement

I (the Participant) have been offered the opportunity to participate in and/or volunteer to help with social activities organized by Integrated Community Solutions, Inc., (ICS) a non-profit Ohio charitable corporation. I want participate in ICS programs because it gives me pleasure and satisfaction to be involved with others who are developmentally disabled, or who are family and friends of people with developmental disabilities. I fully understand and accept the risks involved in these activities.

As consideration for being provided this valuable opportunity, I will hold harmless and indemnify ICS, its directors, agents, volunteers and employees, from any and all losses, claims, actions or proceedings of every kind and character, including claims for negligence and for damages of any kind, including damage to property, personal injury or death which may arise directly or indirectly from my presence at ICS locations, and my participation in ICS activities. I agree to abide by all policies, procedures and instructions adopted by ICS as they may change from time to time.

I understand that ICS will take pictures and videos during various social engagement opportunities. I give ICS permission to use my likeness, photo, video to promote ICS, and raise funds for the organization. I understand that I will not be compensated for this. If I do not agree to this, I will discuss this with the group coordinator.

I certify that I have the legal authority selected above, have read the ICS Waiver Agreement in its entirety, understand its terms, and voluntarily agree to be legally bound by it.

Guardian's Full Name. If participant does not have an appointed Guardian, please enter participant name.

First NameLast Name

Guardian's Relationship to Participant. If participant does not have an appointed Guardian, please select Self.

Guardian's Email Address. If participant does not have an appointed Guardian, please enter participant's email, or other email we may contact.

example@example.com

Guardian's Phone Number. If participant does not have an appointed Guardian, please enter participant's phone number.

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

Emergency Contact Name

First NameLast Name

Emergency Contact Phone Number

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

Signature

Date

Hour MinutesAM/PM Option

You will be emailed a registration receipt, with all group selections. PLEASE CHECK JUNK FOLDER if you do not see your registration receipt in your Inbox.

ICS October 2026 Activities Registration Form

Please indicate which activities you plan to attend.