2022 Paul Schulte Basketball Clinic Registration

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Youth with Disabilities, 18 and Under.
Sunday, May 1st, 2022 9:00 a.m.-12:00 p.m.
Gault Recreation Center at Wooster High School, 515 Oldman Road, Wooster, Ohio 44691

First Name *

Last Name *

Gender *

Male

Female

Date of Birth *

Email Address *

Street Address *

City *

State *

ZIP Code *

Phone number *

Disability *

Describe your disability (level of injury, movement limitation, cognitive or sensory involvement) *

Which of the following do you use for mobility? *

Wheelchair

Crutches

Walker

Other:

Do you own a basketball chair? *

Yes

What is your level of experience or number of years playing wheelchair basketball? *

None, first time

Beginner, 1-2 years

Intermediate, 3-5 years

Advanced, 5 years+

If you play on a team, what is the team/coach's name? *

Any other info you would like to share

ASPO Waiver, Release of Liability, and Consent for Medical Treatment: I am aware and understand that there are certain risks associated with my participation in Adaptive Sports Ohio's activities, programs, and events, including but not limited to risk of injury, loss, death, and property damage. I also acknowledge that any injuries, loss, death, or damage I sustain could be compounded by negligent emergency response or rescue operations of Adaptive Sports Ohio. I acknowledge that I am knowingly and voluntarily participating in Adaptive Sports Ohio's activities, programs, and events with an express understanding of the danger involved and hereby agree to accept and assume any and all risks of injury, loss, death, or property damage, whether caused by or that may result from the negligence of Adaptive Sports Ohio, Adaptive Sports Ohio's directors, officers, sponsors, employees, other agents, and assigns, or any other participant in Adaptive Sports Ohio's activities, programs, or events, to the fullest extent permitted by law. Assumption of Risks from Communicable Diseases, Including COVID-19: I am aware and understand that one of the risks associated with my participation in Adaptive Sports Ohio's activities, programs, and events is the risk of direct or indirect contact with individuals who have been exposed to and/or diagnosed with one or more communicable diseases, including but not limited to COVID-19 or other medical conditions, diseases, or maladies, and/or any mutation or variation thereof. I am aware and understand that such risk exists and that it is impossible to eliminate the risk that I could become infected through contact with or close proximity to an individual with a communicable disease, and that such infection could result in injury, loss, death, or other damage. I knowingly and freely assume all such risks, both known and unknown, including those arising from the negligence of Adaptive Sports Ohio, its agents, and other participants in Adaptive Sports Ohio's activities, programs, or events, and I assume full responsibility for my participation. Additionally, I willingly agree to comply with the stated and customary terms and conditions for participation in Adaptive Sports Ohio's activities, programs, and events, and I acknowledge that I agree to comply with its terms. *

I have read this Waiver, Release, and Consent and understand and agree to the terms and conditions contained herein. I am signing this Waiver, Release, and Consent voluntarily.

As a parent or legal guardian of the above named child, I verify that I fully agree to, understand, and accept all provisions of this Waiver, Release and Consent.

Required

CONSENT TO PHOTOGRAPH: Adaptive Sports Ohio is hereby given permission for photographing, recording, and/or illustrating of an individual for release to the news media, promotional, and/or recruiting purposes. *

By checking this box, I am giving my consent voluntarily.

As a parent or legal guardian of the above named child, I verify that I fully agree to, understand, and accept all provisions of this Consent to Photograph.

Required

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