Created 2017 by KG; Reviewed on 1/2018 by AO; Edited on 2/22/18 AO; Edited 1/1/19 AO

BURKE REHABILITATION: ADAPTIVE SPORTS & RECREATION 2019 Before your participation in Burke’s Adaptive Sports & Recreation program, this form must be

completed in its entirety. This information is essential to our ability to facilitate a successful experience. All sections should be completed. Please be thorough and accurate.

Today’s Date (MM/DD/YYYY): ____ /____ /______

Name(s) & Date(s) of clinics/program(s) you are registering for: _____________________________________

________________________________________________________________________________________

Contact/Biographical Information

Participant Name:_________________________________ Home Phone:_____________________________

Email: __________________________________________ Cell Phone: _________________________________

Address: __________________________________________ City: _______________ State: ___ Zip: _________

Name of Parent/Guardian (if applicable): _______________________________________________________

Relation to participant: _______________________ Parent/Guardian Phone: __________________________

Emergency Contact: _____________________________ Relation:_______________ Phone: _______________

Primary Physician: _________________________________ Physician Phone: ___________________________ (If no primary physician, please list 2nd emergency contact) (or 2nd emergency contact number)

Disability/Medical Information

Date of Birth (MM/DD/YYYY): ____ /____ /______ Height:_______ Weight:______ Gender:________________

Participant Disability/Diagnosis: (**PLEASE BE SPECIFIC HERE. LIST ANYTHING THAT MAY AFFECT YOUR PARTICIPATION!**)

________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________

Are there any mental health/behavioral needs of which staff should be made aware? ________________________________________________________________________________________

________________________________________________________________________________________

If disability was caused by injury/incident, please give the date (MM/DD/YYYY): ____ /____ /______

Any injuries/surgeries in the past year? ________________________________________________________

________________________________________________________________________________________

Currently taking any medications? If yes, please list: _______________________________________________

__________________________________________________________________________________________

Created 2017 by KG; Reviewed on 1/2018 by AO; Edited on 2/22/18 AO; Edited 1/1/19 AO

Allergies (food, medications, latex, bees, other)?: _________________________________________________

Do you have a known anaphylaxis reaction to the allergen above? ____________________________________

If yes- do you carry and Epinephrine Auto Injector (EpiPen)? ___________________________________

If yes- do you give Burke permission to administer your epinephrine to you, if you are unable to do so? _________________

Subject to seizure? ________ Date of last seizure (MM/DD/YYYY): ____ /____ /______

Seizure management (Meds, etc.) _____________________________________________________________

Can participant wear a helmet? _______________________________________________________________

Please describe any other medical concerns that may affect participation: ______________________________

__________________________________________________________________________________________ __________________________________________________________________________________________

Physical/Social Information

Mobility: Independent Independent (requires extra time) Needs assistance

Devices used to aid mobility (check all that apply):

Braces Walker Cane Manual wheelchair Power wheelchair Crutches Other: ___________________________________________________________________________________________

Transfers: Independent Supervision Minimal Moderate Maximal

Please describe any and all pertinent information regarding transfers: ______________________________________ __________________________________________________________________________________________

Please describe any hearing and/or visual abilities and any special needs/concerns: _______________________ ___________________________________________________________________________________________ Please describe any pertinent information regarding the participant’s means of communications and interactions with others. Please include any stressors, motivators, or other relevant information.

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Continued >

Created 2017 by KG; Reviewed on 1/2018 by AO; Edited on 2/22/18 AO; Edited 1/1/19 AO

How did you hear about us? ____________________________________________________________________________________________________________________________________________________________________________________

What activities are you (the participant) interested in participating in?

Hand Cycling Snow/Water Skiing Sailing Visual Arts Dance

Rock Climbing Kayaking Yoga Creative Writing Recreation Outings

Boxing Golf Table Tennis Theater/Improv Other

Please describe your experience with the selected activities above, including equipment adaptations, personal goals, and any other specific information that will help us prepare for your participation: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please describe your… Left Side Right Side

Arm strength

Hand grip strength

Arm/Hand sensation (numbness, tingling, etc.)

Arm range of motion

Leg strength

Leg/Foot sensation (numbness, tingling, etc.)

Leg range of motion

Created 2017 by KG; Reviewed on 1/2018 by AO; Edited on 2/22/18 AO; Edited 1/1/19 AO

Would you like to know more about our other programs, and stay up to date to our upcoming programs and available resources? (I.E. Fitness classes, fitness challenge, cycling races, fundraisers, wheelchair games, etc.)

Yes! Email to reach you at: __________________________________________________________

No thank you

BURKE ADAPTIVE RECREATION RELEASE

RELEASE OF LIABILITY (required)

I/we hereby for ourselves, our heirs, administrators and assigns, waive and release any and all claims against The Burke Rehabilitation Hospital and its employees, contractors and volunteers, for any and all injuries and/or expenses incurred by me/us while using any related recreation equipment (such as McClain Training Rollers, Quad Grips, helmets, Hand Cycles, Golf Clubs, Climbing Equipment, Kayaking Equipment, Table Tennis Equipment, etc.) during participation in clinics, classes, workshops, practices, training, rides or competition.

Printed Name of Participant: ___________________________________________________

Signature of Participant: ___________________________________ Date: ______________

Legal Guardian: __________________________________________ Date: ______________

Questions? Call (914) 597-2248 and leave a message. We will return your call as soon as possible.

After you have completed this form in its entirety,

please return to:

Therapeutic Recreation c/o Alexandra Oudheusden Burke Rehabilitation Hospital

785 Mamaroneck Ave. White Plains, NY 10605

AdaptiveSports@Burke.org FAX: 914-597-2829

Street Address City State Zip

Code

Burke Rehabilitation Hospital

785 Mamaroneck Avenue, White Plains, New York 10605

Marketing Department

(914) 597-2848

Photo Release Form

I, _________________________________________________________ (print name)

Residing at: _________________________________________________________________________________

hereby authorize Burke Rehabilitation Hospital and its parent, successors, affiliates (hereinafter “Burke”) and

such other persons as it may engage (“Licensees”), to interview me, take and use still and/or motion pictures,

voice and videotape recordings of me, my children, or my legal ward while a patient or visitor of Burke.

I authorize the use of these pictures and/or recordings, together with the right to retouch or edit the same, in any

manner and in any media for the purpose of advertising Burke’s services or any other purpose which Burke may

deem appropriate.

I understand that any pictures/videos taken of me by Burke or Licensees are owned by them and may be included

in publications posted on Burke’s website, marketing materials and social networking sites.

I further agree that Burke and Licensee will have the right to attribute to me any statement made by me and said

statement may be paraphrased, amplified and/or shortened.

I recognize that the protected health information used or disclosed pursuant to this authorization may be subject to

re-disclosure by the recipient and may no longer be protected.

I am over 18 years of age and have the legal right and authority to sign for myself and any minors named herein.

I hereby release Burke and Licensees form any claim or liability whatsoever in connection with the

photos/filming.

Date: ___________________________

Signature: ____________________________________

Subject/Project: _______________________________

Employee: ___________________________________

*Please return form to Burke’s Marketing Department (Revised 01/18)