Dear STRIDE Applicant,

Thank you for taking the time to fill out a STRIDE Application for your child’s participation in our programs. Once STRIDE receives your application in the mail, it is reviewed and filed. Your application is good for two years. Your name and address and pertinent information you provided is entered into our database. You will then be on our mailing list to receive STRIDE’s Newsletter and mailings. Our newsletter announces all upcoming programs and special events. It is your responsibility to stay in touch, and to make reservations for any of our programs or events. Most information can be located on the website, www.stride.org.

The information you provide us is confidential and used soley for educational and safety purposes. The liability waiver is for our insurance and must be signed. A valid Credit card # must be kept on file for camping and skiing programs in the event that cancellations are not made in a timely manner, and volunteers are kept waiting at the expence of other participants who could have taken that spot.

Guidelines: The participant must be at least 4 years old; and have an IEP on file at his/her school district. Adults over 21, may only participate in the ski/snowboard programs or the Alumni Program.

Please understand that STRIDE is an all volunteer organization and this process works best for us. If you have any questions or concerns you can contact the STRIDE office at (518) 598-1279.

Please enclose a school photograph if you can.

Sincerely,

STRIDE, Inc. Administration

STRIDE, Inc.

Adaptive Sports

PO Box 778 Rensselaer, NY 12144

518.598.1279 Fax: 518.391-2563

2008-09 APPLICATION FOR PROGRAMS

Demographic Information

Participant's name: ____________________________________________ Age: ____ Gender:____ D.O.B.: ____________

Parents/guardian: _____________________________________________________________________________________

Address: __________________________________________City/State: __________________________Zip: ______________

Phone: ____________________ Emergency/cell phone: _______________________Work phone____________________

E-mail address: _________________________________ Parent/guardian occupation(s): ______________________________

Place(s) of employment:__________________________________________________________________________________

Education and general disability information

Disability classification: ___________________________________________________ Educational level: ________

Enrolled in Special Education: Yes ____No ____ Receives Adaptive Physical Education? Yes _____ No _____

Personal Data: Height:______ Weight: ______ Shoe size: ______ General Physical Condition: _________

Other Activities & Sports Involvement:

___Special Olympics ___Games for the Physically Challenged Other: (Please list)___________________

Special equipment or care needs:

Please list adaptive equipment needs for participation in activities (e.g.: wheelchairs, splints, walk aids, swim aids, etc.) ________________________________________________________________________________________

________________________________________________________________________________________________

STRIDE Programs:

Participant wishes to sign up for the following activities:

Alpine skiing or snowboarding : Weekend camping: Bowling: Swimming:

____Jiminy Peak or ___Catamount June _____ Spring _____ Albany______

____Ski Sundown July _____ Summer_____ Berkshires _____

____Weekends ___Nights Aug _____ Fall________

Sept. _____ Winter______ Golf: ________

Little League Baseball ______ (May - July) Snowshoe/XC Ski _______ Biking: Session 1_____
Session 2 _____

Sailing Program Special Events ____

Lake George __________ Dance________

New Rochelle __________ Whitewater_____

Berkshires _______

Form completed by: __________________________________________________ Date: __________________

This form is to be completed and signed by:

Primary Physician or Physical Therapist (if applicable):

Name: ____________________________________________________________________________

Address: __________________________________________________________________________

Phone: ____________________________________________________________________________

Hospital: _______________________________________________________

Disability diagnosis and degree of involvement: ___________________________________________________

__________________________________________________________________________________

Past surgical procedures: ______________________________________________________________

__________________________________________________________________________________

Medications used (give dosage, frequency and reason): _____________________________________

__________________________________________________________________________________

Pertinent information regarding physical status of participant: (e.g.: allergies; ROM; spacticity;

sensory losses; seizure activity w/ date of last seizure, diabetes, heart, hearing loss, glasses, or contacts):

__________________________________________________________________________________

Other Comments: ___________________________________________________________________

__________________________________________________________________________________

Endurance level_____________________________________________________________________

Physician or Physical Therapist Signature: _______________________________ Date: ____________________

*Information provided is strictly confidential and is used solely for safety purposes in administering our programs.

You may fax this form to STRIDE Business office 518-391-2563

This form to be completed by teacher, therapist, or parent/guardian:

Participant’s Behavior and General Attitudes

CODE

1. Normal - no problems

2. Mild problems - interferes occasionally

3. Moderate problems - interferes frequently

4. Severe problems - interferes constantly

Please circle at the appropriate code:

Frustration tolerance 1 2 3 4

Hostility 1 2 3 4

Confusion 1 2 3 4

Attentiveness 1 2 3 4

Distractibility 1 2 3 4

Impulsivity 1 2 3 4

Anxiety 1 2 3 4

Following Directions 1 2 3 4

Sequencing 1 2 3 4

Problem Solving 1 2 3 4

Slowness of Cognition 1 2 3 4

Temper 1 2 3 4

*Additional comments or Information: _____________________________________________________

____________________________________________________________________________________

*Please note that we reserve the right to refuse participation based on safety considerations, if pertinent information related to safety is withheld.

Form completed by: ___________________________________________________________________

Position/Relationship: __________________________________________ Date: ___________

STRIDE, Inc / and DS/USA INSURANCE WAIVER & RELEASE OF LIABILITY FORM

and MEDIA RELEASE FORM

Please note: there are two places on this sheet that require a signature

In consideration of being allowed to participate in any way in STRIDE Inc. and/or DISABLED SPORTS USA’s programs, related events, and activities, I and/or the minor participant, for myself, and on behalf of my heirs, assigns, personal representatives and next of kin, the undersigned:

1. Agree that prior to participating, I will inspect, or if a parent and/or legal guardian I will instruct the minor participant to inspect, the facilities and equipment to be used, and if I believe, to the best of my ability, that anything is unsafe, I and/or the minor participant will immediately advise STRIDE, Inc. and/or DISABLED SPORTS USA of such condition(s) and refuse to participate.

2. Acknowledge and fully understand that I and/or the minor participant, will be engaging in activities that involve risk of serious injury, including permanent disability and death, and severe social and economic losses which might result only from my own actions, inactions or negligence of others, the rules of play, or the condition of the premises or any equipment used. Further, that there may be other risks not known to me or not reasonably foreseeable at this time.

3. Assume all the foregoing risks and accept personal responsibility for the damages following such injury, permanent disability or death.

4. Release, waive, discharge and covenant not to sue STRIDE, Inc. and/or DISABLED SPORTS USA, its affiliated clubs, their representative administrators, directors, agents, coaches, and other employees of the organization, other participants, sponsoring agencies, sponsors, advertisers, their heirs, and if applicable, owners and leasers of premises used to conduct the event, all of which are hereinafter referred to as "releasees", from demands, losses or damages on account of injury, including death or damage to property, caused or alleged to be caused in whole or in part by the negligence of the releasee or otherwise.

I/WE HAVE READ THE ABOVE WAIVER AND RELEASE, UNDERSTAND THAT I/WE HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, HAVE NOT CHANGED IT ORALLY, AND SIGN IT VOLUNTARILY.

X__________________________________________________________________________________________

Participant's Name (PLEASE PRINT CLEARLY) Signature Date

FOR PARTICIPANTS OF MINORITY AGE

This is to certify that I, as parent/guardian with legal responsibility for this participant, do consent and agree to his/her release as provided above of the Releasees, and, for myself, my heirs, assigns, and next of kin, I release and agree to indemnify and hold harmless the Releasees from any and all liabilities incident to my minor child's involvement or participation in these programs as provided above, EVEN IF ARISING FROM THEIR NEGLIGENCE.

X__________________________________________________________________________________________

Parent's Signature & Emergency Phone Name & Date

____________________________________________________________

MEDIA RELEASE FORM

PERMISSION TO ADMINISTER MEDICATIONS

I, _________________________________, parent/guardian of _______________________________

give my permission for STRIDE volunteers to administer the necessary medications as prescribed to my son/daughter , as needed, in my absence.

Signed__________________________________________________Date__________________________

Medications: Please name all meds to be administered and for what purpose/ dosages and times to be administered:

________________________________________________________________________________________

SUNSCREEN AND INSECT REPELLENT PERMISSION SLIP

I, _____________________________________ hereby give my permission for my child ________________________,

Permission to apply___________________________________& __________________________________________.

I understand that sunscreen/repellent are considered medication by the Departtment of Health and that failure to return this note along with my child’s personal sunscreen and repellant may result in serious sunburn of insect bites. Blanket signature will allow STRIDE to apply their supply of screen and repellant where applicable.

I hereby authorize and give full consent to STRIDE Adaptive Programs and/or Disabled Sports USA to copyright or publish all photographs, videotapes and films in which I, the undersigned, appear while enrolled in this program. I further agree that STRIDE and/or Disabled Sports USA, may transfer, use or cause to be used, these photographs, videotapes or films for any exhibitions, publications, public displays, publication commercials, art and advertising purposes, and television programs without limitations or reservations. I also permit STRIDE and/or Disabled Sports USA, to release my name and phone numbers to the media.

CANCELLATION POLICY FOR PROGRAMS

STRIDE must keep on file an valid Credit Card # in the event that participants with reservations for programs do not follow cancellation protocol for all programs.

Participants Name__________________________________________________________________________

Credit Card# : __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ Card: VISA MC Exp. Date:______________

Name on Card_________________________________Signature__________________________________________
(Please Print)