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TherapeuticRecreationProgramSpring/
Summer 2016
TherapeuticRecreationProgramSpring/
Summer 2016
eastersealswcpenna.orgEaster Seals Western and Central Pennsylvania
eastersealswcpenna.orgEaster Seals Western and Central Pennsylvania
Mack Madness Inc.York Community FoundationAmbassador Foundation
Thank You to our recreation program donors:
Utz Quality FoodsBaltimore LifeRoger and Jana Whitelaw
Damian Salvi
Sponsors
THERAPEUTIC RECREATION ADVENTURE SPORTSSPONSORED IN PART BY:
Youth Ambassador Sponsor:
Gamler’s Boatyard and CampgroundPequea Water Ski Club
Sageworth Trust Company (Arlene Utz Hollinger Foundation)
Autism York
VFW Post 7530American Legion John Lloyd Post 404
The Sides Group at RBC Wealth Management
The McAllister Foundation
Easter Seals 2016 Therapeutic Recreation programs are sponsored in part by generouscontributions from The Hershey Company, Highmark, Glatfelter Insurance Group, The Jan Kevern Memorial Golf Tournament, Primerica, and Sweet Charities.
Elizabeth Bunting, CTRSTherapeutic Recreation Program Coordinator - Camping and Respite [email protected]
Joshua WolfeTherapeutic Recreation Program Coordinator - Capital [email protected]
383 Rolling Ridge Dr. State College, PA 16801 888-372-7280 (toll-free)
Corporate Office153 Perry Highway, Pittsburgh, PA 15229Phone: 412- 281-7244
3029 North Front St. Harrisburg, PA 17110 Phone: 717-901-3993
2550 Kingston Rd. Suite 219, York, PA 17402Phone: 717-741-3891 / Fax: 717-741-5359
EASTER SEALS WESTERN AND CENTRAL PENNSYLVANIA
Easter Seals Locations
Matthew Ernst, CTRSDirector of Therapeutic [email protected]
James G. BennettPresident and [email protected]
Shane GemmillTherapeutic Recreation Program Coordinator - Camping and Respite [email protected]
CHECK US OUT ON FACEBOOK AT www.facebook.com/escpa
In today’s world, almost everything is done online. Students who have access to the Internet in their homes can complete homework assignments, research and type book reports, access extra study help, apply to colleges, and more. Parents benefit, too. With the Internet, they can pay bills online, find health and job resources, and connect with teachers. And with Comcast’s Internet Essentials, the nation’s most comprehensive broadband adoption program, eligible families have access to affordable Internet at home.
Internet Essentials aims to bridge the digital divide by offering broadband service for $9.95 a month; the option to buy an Internet-ready computer for less than $150; and free digital literacy training in print, online or in person to families that have at least one child eligible to participate in the National School Lunch Program (NSLP).
To see if you or a family you know may qualify for Internet Essentials, or if you have questions or would like more information please visit InternetEssentials.com or InternetBasico.com or call 1-855-846-8376 and for Spanish, 1-855-765-6995.
TABLE OF CONTENTSWelcome & Mission Statement 5
Recreational Horseback Riding 7
Bowling 8
“Splash It Up” Aquatics 9Climbing Clinic 10
2016 Summer Camps 6
P.K. Filling Adapted Water Sports 11
Fitness Fantastic 12
ACES - Adventure Weekend 1413ACES - Achieving Community Experiences & Skills
Club Lily Adult Respite Weekend 15
Project Beacon Military Respite Weekend 16
All Abilities Social Group 17
Art for All - Capital Area 18
“Reach the Peak” Climbing Program 19Registration Form 20-23
Waivers 24
5
WELCOME
OUR MISSION
Matthew B. Ernst; CTRS Director of Therapeutic Recreation
Easter Seals provides exceptional
services to ensure that all people
with disabilities have equal
opportunity to live, learn,
work and play.
The spring and summer of 2016 are filled with programming for you to both benefit from and enjoy! We are excited to continue offering programs such as aquatics and horseback riding, not to mention one-of-a-kind programs such as the Fitness Fantastic and the P.K. Filling adaptive water sports clinic in August!
Eighteen years later, our programming continues to expand and remain strong. With day camps in three counties, 5 residential camp opportunities, serving both children and adults as well as military children, there are opportunities to match everyone’s needs!
Whether it is at a community based program or at camp, please join us in activities where you can learn, have fun and make new friends!
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2016 summer camps
Residential Camps
If interested in more information on the above camps, please call Matt Ernst at 717-741-3891, ext. 4338 or e-mail him at [email protected] Details are available in our 2016 spring respite and summer camps booklet.
Club LilyAges: 18 and upLocation: Camp VictoryJune 5 – 9 andAugust 21 – 25
Camp KidetPA Army Guard Children Ages: 7 – going into 12th gradeJune 16 - 19
Camp Amp Mini SessionAges: 7 to 17Location: Camp SwataraJune 24 - 26
Camp AmpAges: 7 to 17Location: Camp Joy ElJuly 31 – August 5
Day Camps
York CountyMonday-Friday8:30AM – 3:30PMChurch of the Open DoorJune 20 – August 5 (off week of July 11th)
Cumberland CountyMonday-Friday9:00AM – 3:00PMLower Allen Community ParkJuly 18 – August 12
Adams CountyMonday-Friday9:00AM – 3:00PMYWCA Gettysburg and Adams CountyJuly 25 – August 5
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RECREATIONAl horseback ridingEaster Seals Recreational Horseback Riding is a six-week program providingchildren and adults with special needs the opportunity to enjoy horses whileriding and learning new skills. As the weeks progress, riders will become morecomfortable, sit higher in their saddle, participate in activities, and learn to controltheir horses through reins work and other activities. Volunteers and staff workwith riders to make recreational riding both fun and therapeutic. Benefits includeimproved self esteem, enhanced balance, improvement in both fine and gross motorskills and increased strength.A doctor’s note is required for participation in this program.
Star Stables Sessions:(York County - Red Lion)
Tuesday EveningsMay 24 - June 28, 2016July 12 - August 16, 2016
5:30 PM – 6:05 PM6:10 PM – 6:45 PM
Cost: $200.00 per 6:50 PM – 7:25 PMsix weeks 7:30 PM – 8:05 PM
Indigo Stables - Mechanicsburg(Cumberland County)
Monday EveningsApril 18 - May 23, 2016
Sessions:5:00 PM – 5:35 PM5:40 PM – 6:15 PM
Cost: $200.00 persix weeks
6:20 PM – 6:55 PM
Indigo Stables -Mechanicsburg
Saturday Afternoons:April 23 - May 28, 2016
Sessions:1:00 PM – 1:35 PM
(Cumberland County) 1:40 PM – 2:15 PM2:20 PM – 2:55 PM
Cost: $200.00 per
six weeks
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BOWLING
ABC West Friday EveningsApril 15 - May 20, 2016June 3 - July 8, 2016July 22 - August 26, 2016
Sessions:
Strike up new friendships while having fun! Proper bowling techniques will be taught along with an explanation of rules and scoring. Participants will improve hand-eye coordination, socialization, and range of motion. Adaptive ramps and other modifications are available for those with special needs.
(Mechanicsburg) 5:30 PM – 7:00 PM(Cumberland County)
Includes 2 games,
shoes, pizza orCost: $75.00 per hot dog, chips and six weeks
a drink.
ABC East Wednesday EveningsApril 13 - May 18, 2016June 1 - July 6, 2016July 20 - August 24, 2016
Sessions:(Dauphin County) 5:30 PM – 7:00 PM
Cost: $75.00 per Includes 2 games,
six weeks shoes, pizza or
hot dog, chips and
a drink.
Laser Alleys(York County)
Thursday EveningsMay 12 - June 16, 2016July 7 - August 11, 2016
Sessions: 6:00 PM – 7:30 PM
Cost: $70.00 persix weeks
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"SPLASh it up” AquaticsNothing says fun and excitement like swimming! Our “SPLASH IT UP” AQUATICS program has been designed to accommodate the needs and abilities of each individual participant with a disability or special needs. Lessons will be conducted with a 1:1 or 1:2 instructor to participant ratio. In addition to teaching water safety skills and swimming techniques, this program seeks to enhance the development of physical fitness and appropriate social interaction skills. Please Note: Participants will be placed into time slots and notified of the schedule after the registration deadline.
York YMCA (
Friday Evenings Sessions:(York County)
Hanover YMCA (York County)
Cost: $90.00 per six weeks
May 13 - June 17, 2016July 8 - August 12, 2016
6:00 PM – 6:30 PM
Cost: $90.00 per six weeks 6:30 PM – 7:00 PM
7:00 PM – 7:30 PM
Wednesday Evenings Sessions: May 18 - June 22, 2016
July 13 - August 17, 2016 6:00 PM – 6:30 PM
6:30 PM – 7:00 PM 7:00 PM – 7:30 PM
East Shore YMCA Friday Evenings Sessions:(Dauphin County) April 15 - May 20, 2016
June 3 - July 8, 2016July 22 - August 26, 2016
5:30 PM – 6:00 PM 6:00 PM – 6:30 PMCost: $90.00 per 6:30 PM – 7:00 PMsix weeks
The Carlisle Family YMCA Thursday Evenings Sessions:(Cumberland County) April 14 - May 19, 2016
June 2 - July 7, 2016July 21 - August 25, 2016
5:00 PM – 5:30 PM 5:30 PM – 6:00 PMCost: $90.00 per 6:00 PM – 6:30 PMsix weeks
10
CLIMBINg clinicIndoor rock climbing provides physical, emotional, and cognitive challenges in a setting. Increase your strength, develop your gross motor and problem solving skillsand boost your self esteem on the wall.
Participants of all ages and disabilities are invited to reach for the peak!
Climbnasium (Mechanicsburg)(Cumberland County)Saturday April 9 July 16, 2016
Time: 10:00 AM – 12:00 PM
Cost: $45.00 per Clinic
11
P.K. Filling Adapted Water Sports
Lake Aldred on the Susquehanna River(York and Lancaster Counties)
Saturday and Sunday August 6 and August 7, 2016
Deadline: July 29, 2016
Cost: 1 lesson - $35.00, 2 lessons - $50.00
Time slots will be assigned after your registration is received.
Come enjoy freedom on the water! This program has been recognized by the Pennsylvania Therapeutic Recreation Society for excellence in programming. Whether you are six or sixty, you can be sure that this program will give you a thrill. Take advantage of this unique opportunity and your overall enjoyment for the water. Each year, with the help of the Pequea and Lake Aldred Water Ski Clubs, we take to the Susquehanna River for a fun and exciting weekend of water sports! Whether it is tubing, adaptive skiing, stand up skiing, or a ride on the jet skis, we have an activity for individuals of all abilities including those with mobility impairments.
In partnership with Fitness 4 Focus and Andrews’s Gift Foundation, we are able to provide our Fitness Fantastic program. This program gives participants on the Autism Spectrum a safe environment to accomplish their fitness goals. As strength, coordination and cognitive training are improved upon, participants will also see improvement in focus, flexibility, stamina and self-esteem. This program is for ages 12-24 years old. Please call or email Josh Wolfe at (717) 901-3993 Ext: 5394 or [email protected] for more information.
12
Fitness Fantastic
St. Stephens LutheranChurch’s Fellowship Hall(Cumberland County)
Tuesday Evenings Sessions:
The Vista School Gymnasium(Dauphin County)
Cost: $90.00 per six weeks
April 12 - May 17, 2016May 31 - July 5, 2016July 19 - August 23, 2016
6:00 PM – 6:45 PM
Cost: $90.00 per six weeks
Tuesday Evenings Sessions: April 14 - May 19, 2016
June 2- July 7, 2016July 21 - August 25, 2016
6:00 PM – 6:45 PM
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ACES - Achieving communityexperiences & SkillsOur ACES (Achieving Community Experiences and Skills) program has been created for children with Asperger’s Syndrome and High-Functioning Autism. Allow your child to join in on the fun and adventure of these social groups and camps, where interactive experiences will be positive and memorable! Social interaction and participation is encouraged in a relaxed and comfortable environment. Become part of the ACES group today!
ACES Social Group - Mini Session
Monday Evenings
Ages 10 - 22
June 6 - June 20, 2016
Time and locations will vary.A schedule of locations and activities will be sentcloser to the start.
(York County)
Cost: $45.00 (3-week mini session)
We are also currently offering ACES on Friday evenings in Lebanon County. For more details, call Matt at 717-741-3891x 4338 or email him at [email protected].
This camp is intended to for high-functioning children diagnosed with Autism Spectrum Disorder, ages 11-22 wanting to experience a weekend of adventure. At the ACES Adventure weekend there will be an opportunity for kids to learn about themselves, the outdoors, build relationships and of course have fun!
There will be canoeing, rock climbing, team building games and the group will be cooking some of their own meals.
ACES ADVENTURE WEEKEND
Location:
Ages:
Dates:
Cost: $225.00
Camp Hebron (Halifax, PA)
11 – 22 years old
Friday, Sept 30 (6:00 PM) toSunday, Oct 2 (1:00 PM)
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CLUB LILY ADULT RESPITE WEEKEND
Location:
Ages:
Dates:
Cost:
Camp Victory (Millville, PA)
18–101 years old
Friday, Oct 14 (6:00 PM) – Sunday, Oct 16 (1:00 PM)
$330.00 (Includes snack on Friday, 3 meals on Saturdayand breakfast and lunch on Sunday)
Our Club Lily Weekend Retreat is a great way to take a break from your everyday activities and enjoy nature, games, friends, and fun! Activities will include arts and crafts, group games, a climbing wall, bonfires and more! You don’t want to miss out on this great weekend!
Our weekend retreat is for adults of all functioning levels. We staff the weekend at a 1:3, counselor to camper ratio. There will be a certified/licensed Health Staff at camp toassist with medication administration and basic health concerns. Our exceptional staffgoes through trainings and is dedicated to providing the best care possible for all of ourcampers. In order to maintain the highest quality of care with our ratio we ask thatcampers needing one-on-one behavioral support as well as those with fragile medicalconditions bring a non-parent support person, over the age of 18, to camp with them (we handle these circumstances on a case-by-case basis and ask that you contact us if you feel that your camper may fall into this category).
PROJECT BEACON MILITARY RESPITE WEEKEND
16
This weekend, subsidized by in part by Highmark, private donors and the PA National Guard, is specifically for the children (with and without special needs) of active military members and veterans. The camp is an opportunity for Easter Seals to serve our military families and it’s a great chance for the kids to get away and enjoy some time at camp. We will be playing games, doing arts and crafts, trying out the climbing wall and zip line, eating s’mores and so much more!
Join us for one of these fun weekends!
East Location Camp Victory (Millville, PA – Columbia County)Dates: Friday, Oct 21 (6:00 PM) – Sunday, Oct 23 (1:00 PM)
Ages:5 – 17 years old
Cost: FREE (Includes snack on Friday, 3 meals on Saturday and breakfast and lunch on Sunday)
Our capital area social group, named Saturday Smash, is a once a week class in which we go out into the local community to practice social skills, hang out with peers and simply have fun! Lots of great events are planned for the upcoming spring and summer seasons. Please call or e-mail Josh Wolfe at 717-901-3993, ext 5394 or [email protected] to find out more details and to receive updates about the activities. This programs is for ages 13 and up.
17
Location will vary(Capital Area)
SaturdaysApril 16 - May 21, 2016June 4 - July 9, 2016July 23 - August 27, 2016
Time: Varies Cost: $100.00 per six week session
ALL-ABILITIES SOCIAL Group - saturday smash
Now offered as a collaboration with the Art Association of Harrisburg in the capital region, our progressive art program is for individuals ages 10 and up who are looking for a great way to have fun and express themselves! During this program, participants will learn about art techniques and design, as well as create original pieces. The program will provide participants with the opportunity to feel a sense of accomplishment, improve fine motor skills, work on concentration and focus skills, develop a hobby and relax!
Multipurpose Room/Studio at Reservoir Park (Dauphin County)
Tuesday EveningsApril 12 - May 17, 2016May 31 - July 5, 2016August 9 - September 13, 2016
Time: 6:00 PM – 7:00 PM
Cost: $90.00 per six-week session
ART FOR ALL - CAPITAL AREA
18
Do you have a sense of adventure? Then we have great news for you! Ourexclusive rock wall climbing program intended for people with disabilities. We have designed a program that is fit for all social, physical, and developmental needs. Our 8-week program will help develop a strong core, increase physical health, increase self awareness, challenge your endurance and foster socialization, among many other benefits. For ages 6 and up, this program will bring new and exciting challeng-es each week and is set up for you to successfully accomplish them. We hope you will join us in this exhilarating component to our adventure sport programming.
*A doctor’s note is required for participation in this program.
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“reach the peak” climbing program
The Climbnasium (Mechanicsburg, PA)
Saturday Evenings
May 7 - June 25, 2016
6:00 – 8:00 PM
Cost: $175.00 for 8 weeks
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REGISTRATIOn form
PLEASE PRINT:
____________________________________ Sex: M F _____
______
First and Last Name
Height
Weight
____________________________________________________________Address
_____________________________
______________
_____________
City
State
Zip
_________ _________________________
________________________
Age
Disability
Phone (with area code)
____________________________________________________________Email Address
______________________________ _____________________________
Work Phone
Cell Phone
____________________________________________________________Emergency Contact (other than parent or guardian)
______________________________ _____________________________
Relationship to Participant Phone Number(s)
Please return the registration form with payment to:Easter Seals Therapeutic Recreation, 2550 Kingston Rd. Suite 219,York, PA 17402. It is the participants (parents and guardians) responsibility to provide Easter Seals with the most up-to-date information on allergies, medications, behaviors, etc.
Please check here if the parent/guardian is an active member of the military or a veteran.
PLEASE NOTE: Annual Registration Fee (payable once per calendar year)
$20.00 - one participant $35.00 - two participants $45.00 - family
Bowling:
ABC West – Jun 3 – Jul 8 ($75.00)ABC West – Jul 22 – Aug 26 ($75.00)
ABC West – Apr 15 – May 20 ($75.00)
PROGRAM PAID BILL
Recreational Horseback Riding:Star Stables – May 24 – Jun 28 ($200.00)Star Stables – Jul 12 – Aug 16 ($200.00)
Indigo Stables – Apr 18 – May 23 ($200.00)Indigo Stables – Apr 23 – May 28 ($200.00)
Fitness FantasticSt. Stephens Lutheran Church’s Fellowship Hall – Apr 12 – May 17 ($90.00)St. Stephens Lutheran Church’s Fellowship Hall – May 31 – Jul 5 ($90.00)St. Stephens Lutheran Church’s Fellowship Hall – Jul 19 – Aug 23 ($90.00)
“Splash it Up” Aquatics:
York YMCA – May 13 – June 17 ($90.00) York YMCA – Jul 8 – Aug 12 ($90.00)
Climbing Clinics:Climbnasium (Mechanicsburg) – April 9 ($45.00 each)Climbnasium (Mechanicsburg) – July 16 ($45.00 each)
P.K. Filling Adapted Water SportsLake Aldred Aug 6 & 7 – Saturday ___ Sunday ___ ($35.00 for a Lesson/ $50.00 for 2)
ACES Achieving Community Experiences & Skills Social Group - Mini Session:ACES Ages 10 – 22 York – Jun 6 – Jun 20 ($45.00)
ACES Adventure Weekend:ACES Ages 12 – 22 Lebanon – Sept 30 – Oct 2 ($225.00)
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Hanover YMCA – May 18 – Jun 22 ($90.00)Hanover YMCA – Jul 13 – Aug 17 ($90.00) East Shore YMCA – Apr 15 – May 20 ($90.00)East Shore YMCA – Jun 3 – Jul 8 (off Nov 27th) ($90.00) East Shore YMCA – Jul 22 – Aug 26 ($90.00) Carlisle Family YMCA – Apr 14 – May 19 ($90.00)
Carlisle Family YMCA – Jun 2 – Jul 7 (off Nov 26) ($90.00)
Carlisle Family YMCA – Jul 21 – Aug 25 ($90.00)
ABC East – Apr 13 – May 18 ($75.00)ABC East – Jun 1 – Jul 6 ($75.00)ABC East – Jul 20 – Aug 24 ($75.00)
Laser Alleys – May 12 – Jun 16 ($70.00)Laser Alleys – Jul 7 – Aug 11 ($70.00)
The Vista School Gymnasium – Apr 14 – May 19 ($90.00)The Vista School Gymnasium – Jun 2 – Jul 7 ($90.00)The Vista School Gymnasium – Jul 21 – Aug 25 ($90.00)
Sit Down and Tubing Lessons ___ Stand Up Lessons ___
PROGRAM PAID BILL
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Respite Programs: Club Lily Respite – Oct 14 – Oct 16 ($330.00)
Locations Vary – Saturdays, Apr 16 – May 21 ($100.00)All-Abilities Social Group Saturday SMASH
Locations Vary – Saturdays, Jun 4 – Jul 9 (off Nov 28th) ($100.00)Locations Vary – Saturdays, Jul 23 – Aug 27 ($100.00)
Arts and Crafts: Art for All Capital Area – Apr 12 – May 17 ($90.00)
Art for All Capital Area – May 31 – Jul 5 ($90.00)Art for All Capital Area – Aug 9 – Sept 13 ($90.00)
“Reach the Peak” Climbing ProgramClimbnasium (Mechanicsburg) – May 7 – Jun 25 ($175.00)
PB Military Respite East – Oct 21 - Oct 23 (FREE)
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PARTICIPANt information formName ___________________________________________________________________________Address _________________________________________________________________________City __________________________State ____________________ Zip ______________________Male ___________ Female ____________ Birth date ___________________________________Race ________________________________________Home Phone or TTY (717) __________________________________________________________Work Phone (717) _________________________________________________________________E-mail __________________________________________________________________________Parent or Guardian Name ___________________________________________________________Relationship to Participant ___________________________________________________________Address _________________________________________________________________________City __________________________State ____________________ Zip ______________________Home Phone or TTY (717) __________________________________________________________Work Phone (717) ________________________ Cellular Phone (717) _______________________Emergency Contact (other than parent)Home Phone or TTY (717) __________________________________________________________Work Phone (717) ________________________ Cellular Phone (717) _______________________Participant’s Weight _______________________ Height ___________________________________Primary Disability __________________________________________________________________________________________________________________________________________________Secondary Disability _______________________________________________________________________________________________________________________________________________School/Agency ____________________________________________________________________Allergies _________________________________________________________________________________________________________________________________________________________Medications ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________Major accidents or injuries in past years that could affect activity. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Does the participant need assistance with eating, toileting and/or dressing? Please explain, attach sheets as needed. _________________________________________________________________________________________________________________________________________________Does the participant have problems with communicating, behavior management, etc?Please describe and attach any current behavior management plans being used. _______________________________________________________________________________________________Is participant subject to seizures? Yes No(If yes, what type, frequency, duration, after care/rest needed)________________________________________________________________________________________________________________________________________________________________
Does the participant use a wheelchair? Yes NoManual ________Electric__________Does participant have Down Syndrome? Yes NoIf yes, have x-rays of the vertebrae been taken? Yes NoIf yes, is participant clear of Atlantoaxial Dislocation Condition?Please attach copy of medical exam, if yes to above.
24
Date: _____________________________________________Participant’s Name: __________________________________Signature: _________________________________________Please Print Name: __________________________________(If under 18, parent/guardian signature)Relationship to Participant: ____________________________
Easter Seals Western and Central Pennsylvania is committed to conducting its recreation programs and activities in a safe manner and holds the safety of participants in high regard. Easter Seals continually strives to reduce such risks and insists that all participants follow safety rules and instructions that are designed to protect the participants’ safety. However, participants and parents/guardians of minors registering for programs must recognize that there is inherent risk of injury when choosing to participate in recreational activities. You are solely responsible for determining if you or your minor child/ward are physically fit and/or skilled for the activities contemplated by this agreement. It is always advisable, especially if the participant is pregnant, disabled in any way or recently suffered any illness, injury or impairment, to consult a physician before undertaking any physical activity.Warning of Risk Despite careful and proper preparation, instruction, medical advice, conditioning and equipment,there is still a risk of serious injury when participating in any recreational activities. Not all hazards and dangers can be foreseen. Participants must understand that certain risks, dangers and injuries due to acts of God, inclement weather, slipping, falling, equipment failure, failure in supervision, premises defects and all other circumstances inherent to recreational activities exist. In this regard, it must be recognized that it is impossible for Easter Seals Western and Central Pennsylvania to guarantee absolute safety.Waiver and Release of All Claims and Assumption of Risk Please read this form carefully and be aware that in signing up and participating in this program,you will be expressly assuming the risk and legal liability and waiving and releasing all claims for injuries, damages or loss which you or your minor child/ward might sustain as a result of participating in any and all activities connected with and associated with this program (including transportation services, when provided). When registering by fax, it is understood that the facsimile registration document (including the waiver and release of all claims) shall substitute for and have the same legal effect as the original form.Permission to Treat In the event that I cannot be reached in an emergency, I hereby give permission to the physician selected by Easter Seals Western and Central Pennsylvania to secure and administer treatment, including, but not limited to x-rays, hospitalization and surgical interventions. I also give permission to Easter Seals Western and Central Pennsylvania to obtain related transportation. I recognize and acknowledge that there are certain risks of physical injury to participants in this program, and I voluntarily agree to assume the full risk of any and all injuries, damages or loss, regardless of severity, that my minor child/ward or I may sustain as a result of said participation. I further agree to waive and relinquish all claims I or my minor child/ward may have (or accrue to me or my child/ward) as a result of participating in this program against Easter Seals Western and Central Pennsylvania, including its officials, agents, volunteers and employees (hereinafter collectively referred as “Easter Seals Western and Central Pennsylvania”). I do hereby fully release and forever discharge Easter Seals Western and Central Pennsylvania from any and all claims for injuries, damages, or loss that my minor child/ward or I may have or which may accrue to me or my minor child/ward and arising out of, connected with, or in any way associate with this program.Photos/Video Authorization and Consent I hereby authorize and give my consent to Easter Seals Western and Central Pennsylvania to photograph/video me or my child/ward, and without limitation, to use such photographs/video in connection with promoting/ advertising the services, programs, and facilities of Easter Seals Western and Central Pennsylvania without consideration of any kind. I understand that photos and/or video usage could include, among other outlets, Easter Seals Central Pennsylvania’s website, Facebook, and/or other social media outlets.Personal Information Authorization Consent I further authorize Easter Seals Western and Central Pennsylvania to release personal contact information to other parents/participants when deemed appropriate including names, addresses and phone numbers. I have read and fully understand the above important information, warning and assumption of risk, waiver and release of all claims and photo/video and personal information authorization and consent and agree to all terms and conditions as set forth above.
We would love for you to
join Us!
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400 North Blue Ribbon Avenue, Harrisburg, PA 171121.800.564.7002 • 717.652.3310 | www.higherinfogroup.com
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East
er S
eals
Wes
tern
and
Cen
tral P
enns
ylvan
ia25
50 K
ings
ton
Rd. S
uite
219
York
, PA,
1740
2Re
turn
Ser
vice
Req
uest
ed
Non-
Prof
it Or
g.U.
S. P
OSTA
GEPA
IDPe
rmit
No. 7
92Yo
rk, P
A, 17
792
TherapeuticRecreationProgramSpring/
Summer 2016
TherapeuticRecreationProgramSpring/
Summer 2016
eastersealswcpenna.orgEaster Seals Western and Central Pennsylvania
eastersealswcpenna.orgEaster Seals Western and Central Pennsylvania
