CTHF WHEELCHAIR BASKETBALL REGISTRATION
Have you registered for CTHF programming in 2022?

Please complete the application for all CTHF programs which include Camp Adventure, Virtual Camp, Wheelchair Basketball and Tread Setters adaptive cycling

CTHF WheelChair Basketball Registration Form

Staff/Volunteers may have access to information about my child, which may be relevant to his/her participation in CTHF programs. I understand that only necessary information will be disclosed and that all reasonable steps are taken to protect the privacy and confidentiality of my child's information.
CONSENT FOR DISCLOSURE OF INFORMATION(Required)
Child's Name(Required)
Date of Birth(Required)
Gender(Required)
Ethnicity - Optional
Youth(Required)
Adult(Required)
Date of last clinic

EMERGENCY CONTACT INFORMATION

(if parent/guardian cannot be reached): Identification will be required if picking up/transporting participant

INSURANCE

Please enter your child’s insurance information in the sections that follows.

If your child is not currently covered by medical insurance, you are required to sign release of liability for participant without medical insurance.

Please attach a copy of insurance card to the application

In the event of illness or injury, a reasonable effort will be made to contact you to obtain consent in advance of medical services being given to your child. If we are unable to contact you, CTHF Executive Director and/or Program Director will consent to such services for your child by acting on your behalf, based on the written advance authorization below.
Max. file size: 300 MB.

Authorization for Medical Services

I, the parent/guardian of ___________________________________ have read the above statement regarding the authorization of emergency medical services in the event I cannot be reached. I designate CTHF Executive Director and/or Program Director to authorize medical attention, hospitalization, and surgery as may be required in an emergency because of illness or injuries sustained by my child while participating in CTHF Programs. I hereby assume financial responsibility for hospitalization, medical attention, and surgery provided.

Medical Information

Does your child use assistive devices?(Required)
Does your child use a wheelchair?(Required)

CTHF will not administer medications of any kind – No Exceptions

Other Medical Conditions(Required)
Does your child have any of the following: If yes, please explain in detail
What Level?
Immunizations Current?(Required)
Has the participant received their Covid 19 vaccinations?(Required)
Note - If a participant does not have their Covid 19 vaccinations we are requiring them to wear a mask while participating in CTHF programs.

Activities of Daily Living (ADL)

Complete this section if attending Camp Adventure Day Camps
Does your child need assistance with Eating?(Required)
Toileting?(Required)
(I.e. wheelchair, canes, walker, etc.)
Does your child have a catheter?(Required)
If yes, Is your child able to maintain catheter themselves?(Required)
Describe your child's communication skills(Required)

Behavior

Complete this section if attending Camp Adventure Day Camp
Does the participant have any behaviors of which the staff need to be aware of?(Required)

ADDITIONAL INFORMATION

Complete this section if attending Camp Adventure Day Camp
Can your child swim without assistance?(Required)
Do they require any type of floating device?(Required)
If yes, please provide floating device for camp
Are there key actions, words, or phrases used to stop behavior and redirect?(Required)
Does your child follow directions?(Required)

CONSENTS

Must be completed for all CTHF programs
CONSENT FOR ACTIVITIES(Required)
agree that my child is authorized to participate in any and all officially administered, sponsored or sanctioned activities during a CTHF program, including, but not limited to: (1) Supervised swimming in a pool, (2) Supervised kayaking in the swimming pool or lake, and fishing in a pond/lake, (3) Cycling (4) Supervised Climbing Wall, (5) Carnival and games, (6) Dance. (7) Ice Hockey (8) Indoor Laser Tag

Certain medical conditions may limit participation in specific activities and may require additional medical authorization from your medical provider and/or parent/guardian support.
CONSENT FOR MEDIA RELEASE & SPECIAL PERMISSIONS(Required)
give my permission and approval the use of my child’s image, name, biographical information and/or audio recording to be used by Carrie Tingley Hospital Foundation as part of its fundraising efforts, advertising, publicity, promotion or any other use. I understand and agree that my image, information and/or audio recording may appear in any media now known or hereafter invented including but not limited to print materials, video, online presentations, or other media. I hereby waive any right to inspect and approve the uses to which it may be applied. Nothing herein will constitute any obligation on the Carrie Tingley Hospital Foundation to use any of the above rights.

D) GENERAL CONSENT


I agree that neither the Carrie Tingley Hospital Foundation nor its employees, agents, or volunteers associated with CTHF shall be held responsible for any injuries or damages that occur while my child _(Insert child’s name)________________attends or participates in Camp activities. I do hereby hold harmless the Carrie Tingley Hospital Foundation its employees, agents, and volunteers against any and all liability, damage, loss, claims or demands which arise out of or are in any way connected with my attendance or participation in CTHF programs.
Date(Required)
This field is for validation purposes and should be left unchanged.