Register a Participant

Please fill out this form if you are interested in registering a participant for ConnectAbility programs & events. All information is held confidentially.

 

ConnectAbility Participant Registration

Basic Information

Participant name
Participant name
First
Last
Parent/Guardian/Caregiver
Parent/Guardian/Caregiver
First
Last
Address
Address
City
State/Province
Zip/Postal
Emergency contact name
Emergency contact name
First
Last

Description of participant needs

Does the participant have a diagnosis that we need to know about?
Personal care assistance needs
Does the participant need extra assistance in any area?
Does the participant experience seizures?
Does the participant use a wheelchair or adaptive equipment?

Photo and Liability Release Agreement

I grant to ConnectAbility the right to take photographs and/or video of me, my child and my family in connection with any of the sponsored events. I authorize ConnectAbility, its assignees and transferees to copyright, use and publish the same in print and/or electronically. I give permission to ConnectAbility to use such photographs and/or video of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content. I do hereby release, forever discharge, and covenant to hold harmless ConnectAbility, its staff, employees, and sponsors from any and all liability, claims or demands for personal injury, sickness and death, as well as property damage and expenses, of any nature whatsoever while participating in any event sponsored by ConnectAbility, including travel to and from any activities. This agreement also applies to any and all activities on or off ConnectAbility property. I hereby authorize any staff member and/or adult sponsor who may be supervising or directing any activity sponsored by ConnectAbility, to authorize medical treatment, including but not limited to emergency surgery. I agree to assume liability for any and all costs and expenses incurred, including medical and dental costs, and that ConnectAbility, its staff, employees, and sponsors with them are not responsible. Parent(s) or persons who are designated as emergency contacts will be notified if my child/participant becomes ill or injured. I agree to come in person or to direct the emergency contact to collect my child/participant upon notification. I assume full responsibility for any damage to property and/or equipment caused by my child/participant and I understand I will be responsible for replacement of same.
Using your mouse, draw your signature in the field provided as an acknowledgement of your agreement with the photo and liability release statement statement.