TherapeuticRecreationProgram 2014

Spring/Summer

eastersealswcpenna.orgEaster Seals Western and Central Pennsylvania

CHECK US OUT ON FACEBOOK AT www.facebook.com/escpa

Thank You to our recreation program donors:

Gamler’s Boatyard and Campground

Mechanicsburg Climbnasium

Pequea Water Ski Club

Sageworth Trust Company (Arlene Utz Hollinger Foundation)

Utz Quality Foods

Baltimore Life

Roger and Jana Whitelaw

Autism York

Donna Deerin Ward

Damian Salvi

Alex and Sara Young

Waynesboro Rotary Club

Mack Madness Inc.

York Community Foundation

THERAPEUTIC RECREATION PROGRAM SPONSORED IN PART BY:

The Hershey Company

Highmark

GGS Information Services

Glatfelter Insurance Group

The Stabler Foundation

The McCormick Foundation

The Jan Kevern Memorial Golf Tournament

National Civil War Museum

Pennsylvania Department ofMilitary and Veterans Affairs

EASTER SEALS WESTERN AND CENTRAL PENNSYLVANIAMatthew Ernst, CTRSDirector of Therapeutic Recreationmernst@eastersealscentralpa.org

Elizabeth Bunting, CTRSTherapeutic Recreation Program Coordinator - Camping and Respite Programsebunting@eastersealscentralpa.org

Joshua WolfeTherapeutic Recreation Program Coordinator - Capital Regionjwolfe@eastersealscentralpa.org

EASTER SEALS LOCATIONS:

383 Rolling Ridge Dr. State College, PA 16801 888-372-7280 (toll-free)

Corporate Office2525 Railroad St. Pittsburgh, PA 15222Phone: 412- 281-7244

501 Valley View Blvd., Altoona, PA 16602Phone: 814-944-5014 / Fax: 814-944-6500

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

THERAPEUTIC RECREATION ADVENTURESPORTS SPONSORED IN PART BY:

VISIT NOW AND SAVE!

Show this ad and save up to $6.00 off! ($1 per person off of our general admission for up to 6 people) Cannot be combined with any other discounts. Expires: 03/31/2015 OPEN 7 DAYS A WEEK Except New Years Day, Easter, Thanksgiving & Christmas

1 Lincoln Circle at Reservoir Park Harrisburg, PA 717.260.1861 ~ 866.BLU.GRAY www.NationalCivilWarMuseum.org

TABLE OF CONTENTSWelcome & Mission Statement 5

Easter Seals Camp Sponsors 6

Special Siblings 6

Challenger Baseball 6

Summer Camp for 2014 6

Recreational Horseback Riding 7

Bowling 8

“Splash It Up” Aquatics 9

Scuba Diving 10

Climbing Clinic 11

Bocce Ball 11

ACES - Adventure Weekend 12

Club Lily Adult Respite Weekend 13

Project Beacon Military Respite Weekend 13

All Abilities Social Group 14

Art for All - Capital Area 14

Kayaking Clinic 15

Music and Me 16

Expressions 16

P.K. Filling Adapted Water Sports 17

Registration Form 18-19

Waivers 21

12ACES - Achieving Community Experiences & Skills

5

WELCOME

OUR MISSION

Matt Ernst, Director of Therapeutic Recreationmernst@eastersealscentralpa.org

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 2014 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 kayaking clinic at ski Roundtop in June and the P.K. Filling adaptive water sports clinic in August!

Sixteen years later, our programming continues to expand and remain strong. With day camps in four counties, 4 residential camp opportunities, serving both children and adults as well as military children and ACES, 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!

6

EASTER SEALS CAMP SPONSORSCamp programs sponsored in part by:

Easter Seals and Autism York have joined forces to offer this wonderful opportunity for children who are siblings, ages 5-15, of children diagnosed with ASD. Call Matt at 717-741-3891 for fall details!

Special Siblings

Summer Camp for 2014

Residential CampsClub Lily - Ages 18 +Camp VictoryJune 1 - 5

Camp Amp - Ages 7-17Summer Session 1Camp AlleghenyJune 22 - 27

Camp Amp - Ages 7-17Summer Session 2Camp Joy ElAugust 3 - 8

Camp Military Kid Strong Ages entering grades 2-12Camp VictoryAugust 17 - 23

Day CampsYork County (Mon-Fri)June 23 - July 11 (off July 4) and July 21 - August 8Church of the Open Door

Dauphin County (Mon-Fri)July 7 - 25Bethany Church of Nazarene

Cumberland County (Mon-Fri)July 28 - Aug 15Lower Allen Community Park - The Barn

Franklin/Adams County (Mon-Fri)July 28 - August 15YWCA Gettysburg & Adams County

Specialty CampsACES Camp - Ages 10-22 (Serving those with high functioning autism and Asperger’s Syndrome)York - Locations VaryJuly 15, 17, 18, 22, 24, 25, 29, 31, and August 1

If interested in more information on the above programs, please call Matt at 717-741-3891, ext. 4338 or e-mail him at mernst@eastersealscentralpa.org or Liz Bunting at 717-901-3993 or ebunting@eastersealscentralpa.org

7

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 13 – June 17July 8 – Aug 12 andSept 2 – Oct 7, 2014

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

Star Stables Wednesday EveningsMay 14 – June 18July 9 – Aug 13, andSept 3 – Oct 8, 2014

Sessions:(York County - Red Lion) 5:00 PM – 5:35 PM

5:40 PM – 6:15 PMCost: $200.00 per 6:20 PM – 6:55 PMsix weeks 7:00 PM – 7:35 PM

7:40 PM – 8:15 PM

Total Equine Learning Center

Wednesday EveningsMay 7 – June 11, 2014

Sessions:5:00 PM – 5:40 PM

(Cumberland County) 5:45 PM – 6:25 PM6:30 PM – 7:10 PM

Cost: $200.00 per

Deadline:

May 2, 2014

six weeks

8

BOWLING

ABC West Friday EveningsApril 25 – May 30,June 13 – July 25 (off July 4th) andAug 8 – Sept 12, 2014

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: $70.00 per

hot dog, chips and six weeks a drink.

ABC East Wednesday EveningsApril 23 – May 28,June 11 – July 16 andAugust 6 – Sept 10, 2014

Sessions:(Dauphin County) 5:30 PM – 7:00 PM

Cost: $70.00 per Includes 2 games,

six weeks shoes, pizza or

hot dog, chips and

a drink.

Laser Alleys (Formerly Colony Park Lanes East)

Thursday EveningsJuly 10 – Aug 14, 2014

Sessions:

(York County) 6:00 PM – 7:30 PM

Cost: $70.00Deadline: July 7, 2014

9

"SPLASH IT UP" AQUATICS

Nothing 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.

Hempfield Recreation Friday Evenings Sessions:Commission June 20 – Aug 1, 2014 5:30 PM – 6:00 PM(Lancaster County)

6:00 PM – 6:30 PM 6:30 PM – 7:00 PM

York YMCA (York County)

Friday Evenings Sessions: May 2 – June 6,

June 27 – Aug 8 (off July 4th)Sept 5 – Oct 10, 2014

5:30 PM – 6:00 PM 6:00 PM – 6:30 PMCost: $90.00 per six weeks

6:30 PM – 7:00 PM 7:00 PM – 7:30 PM

Hanover YMCA (York County) Wednesday Evenings Sessions: May 21 – June 25 and

July 9 – Aug 13, 2014 6:00 PM – 6:30 PM

6:30 PM – 7:00 PMCost: $90.00 per six weeks

7:00 PM – 7:30 PM

East Shore YMCA Friday Evenings Sessions:(Dauphin County) April 25 – May 30 and

July 11 – Aug 15, 2014 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 24 – May 29 and

July 10 – Aug 14, 2014 5:00 PM – 5:30 PM

5:30 PM – 6:00 PMCost: $90.00 per 6:00 PM – 6:30 PMsix weeks

Cost: $90.00 per six weeks

10

SCUBA DIVINGGo under water for an exciting and new experience. With trained and certified divers, participants will be taught the basics of SCUBA diving. You must be 12 or older and be able to demonstrate basic swimming skills. Bring a swimsuit and towel and start exploring today.

Location: York YMCA (York County)Saturday July 26, 201412 (Noon) - 2:00 PMCost: $50.00Deadline: July 18, 2014

11

CLIMBING CLINIC

BOCCE BALL

Indoor rock climbing provides physical, emotional, and cognitive challenges in a social setting. Increase your strength, develop your grossmotor and problem solving skills and boost your self esteem on the wall. Participants of all ages and disabilities are invited to reach for the peak!

Check out our summer Bocce Ball programs for individuals ages 16 and up. Family and friends are welcome too. Whether you know how to play or not, it’s a great way to enjoy a relaxing summer evening, learn a new game and meet new friends.

Climbnasium (Mechanicsburg)Cumberland County

Saturdays June 14 – Aug 9, 2014

Time: 10:00 AM – 12:00 PM

Cost: $40.00 per Clinic

Soldiers and Sailors Memorial Park,Mechanicsburg PA (Cumberland County)

Monday EveningsJune 2 – July 7 andJuly 21 – Aug 25, 2014

Time: 6:00 PM – 7:00 PMCost: $50.00 per six-weeks

12

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 GroupMini Session

Monday Evenings

Ages 10 - 22June 2 – June 16, 2014

Time and locations will vary.

A schedule of locations and activities will be sentcloser to the start.

(York County)

Cost: $40.00 (3 week mini session)

ACES ADVENTURE WEEKENDThis camp is intended to for kids with Asperger’s syndrome and high functionautism 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, a ropes course, team building games and the group will be cooking some of their own meals.

Location:

Ages:

Dates:

Cost: $225.00

Camp Hebron (Halifax, PA)

11 – 22 years old

Friday, Sept 26 (6:00 PM) toSunday, Sept 28 (1:00 PM)

13

CLUB LILY ADULT RESPITE WEEKEND

PROJECT BEACON MILITARY RESPITE WEEKEND

Location:

Ages:

Dates:

Cost:

Camp Victory (Millville, PA - Columbia County)

18–101 years old

Friday, Oct 10 (6:00 PM) – Sunday, Oct 12 (1:00 PM)

$330.00 (Includes snack on Friday, 3 meals on Saturdayand breakfast and lunch on Sunday)

Location:

Ages:

Dates:

Cost:

East – Camp Victory (Millville, PA – Columbia County)West – Camp Soles (Rockwood, PA – Somerset County)

5 – 17 years old

East – Friday, Oct 17 (6:00 PM) – Sunday, Oct 19 (1:00 PM)West – Friday, Oct 31 (6:00 PM) – Sunday, Nov 2 (1:00 PM)

FREE (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).

This weekend, subsidized by in part by the Pennsylvania Department of Military and Veterans Affairs, Highmark 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!

14

ART FOR ALL - Capital Area

One Saturday a month we will be in the community, hanging out and having fun! We will have many great events planned this summer so let’s enjoy some fun in the sun with friends, both old and new!

Please call or email Josh Wolfe at 717-901-3993 ext. 5394 or jwolfe@eastersealscentralpa.org to find out more details and receive updates about each month’s activity. This program is for ages 13 and up.

Location will vary(Capital Area)

Ages 13 and upSaturdaysMay 17, June 21, July 26, and Aug 16, 2014

Time: Varies Cost: $100.00 for 4 months ($25.00 per month)Deadline: The week of each activity

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!

ALL-ABILITIES SOCIAL GROUPSATURDAY SMASH

Multipurpose Room/Studio at Reservoir Park (Dauphin County)

Tuesday EveningsMay 6 – June 10, June 24 – July 29,and Aug 12 – Sept 16, 2014

Time: 6:00 PM – 7:00 PM

Cost: $90.00 per six-week session

15

KAYAKING CLINIC

Ski Roundtop (York County)

Saturday, June 14, 2014

Time slots assigned between10:00 AM and 4:00 PM

Cost: $90.00 for 1.5 – 2 hour session

Rain Date: June 21, 2014

Please contact Josh Wolfe at jwolfe@eastersealscentralpa.org to be placed on the list. You will receive the final information once a date has been determined.

We are happy to continue our new and exciting adventure sport opportunity for those in South Central PA: our 2nd annual flat water kayaking clinic! This opportunity will assist in fostering a love of the outdoors, combined with a chance to have fun on the water! Paddlers will have an hour of instruction from an American Canoe Association (ACA) certified instructor to learn technical skills such as the proper way to paddle, how to use your core to control the kayak and much more. Participants will then use the skills they learn in an hour long “free paddle” with obstacle-like challenges. This is a great occasion to get introduced to an exciting recreational activity, or fine tune your paddling abilities! Don’t miss out on this fun day!

16

MUSIC AND ME

“Music and Me” is a collaborative programformed by Easter Seals Western and Central Pennsylvania and WB MusicTherapy. This program, focusing on those individuals diagnosed on the Autism spectrum with a high need for increased verbalization and socialization, will be facilitated by board certified music therapists. Through this program, participants will gain skills that can bebeneficially transferred to other parts of their lives while gaining a new avenue for self expression.

We hope you join us for this exciting opportunity!

Call Matt Ernst at (717) 741–3891 ext 438 for more information.

Call Matt Ernst at (717) 741–3891 ext 438 for more information.

EXPRESSIONS

Expressions, our brand new theatre program specifically designed for those with disabilities ages 11-22, is a new partnership with York Little Theatre. Come out and express yourself while enjoying endless benefits such as enhanced self-confidence, improved sensory skills and creating new friendships, just to name a few. Be the star of the show…we hope to see you on the stage!

17

P.K. FILLING ADAPTED WATER SPORTS

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.

P.K. FILLING ADAPTED WATER SPORTS

Lake Aldred on the Susquehanna River(York and Lancaster Counties)

Saturday and Sunday August 2 & 3, 2014

Time slots will be assigned after your registration is received.

Deadline: July 25, 2013

Cost: 1 Lesson - $35.00 2 Lessons - $50.00

18

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

19

PROGRAM PAID BILLRecreational Horseback Riding:Star Stables – May 13 – June 17 ($200.00)Star Stables – July 8 – Aug 12 ($200.00)

Star Stables – Sept 2 – Oct 7 ($200.00)Star Stables – May 14 – June 18 ($200.00)Star Stables – July 9 – Aug 13 ($200.00)Star Stables – Sept 3 – Oct 8 ($200.00)Total Equine Learning – May 7 – June 11 ($200.00)

Bowling:

ABC West – June 13 – July 25 (off July 4th) ($70.00)ABC West – April 25 – May 30 ($70.00)

ABC West – Aug 8 – Sept 12 ($70.00)

ABC East – June 11 – July 16 ($70.00)ABC East – April 23 – May 28 ($70.00)

ABC East – Aug 6 – Sept 10 ($70.00)

Laser Alleys – July 10 – Aug 14 ($70.00)

Aquatics:Hempfield – June 20 – Aug 1 ($90.00)York YMCA – May 2 – June 6 ($90.00)York YMCA – June 27 – Aug 8 (off July 4th) ($90.00) York YMCA – Sept 5 – Oct 10 ($90.00) Hanover YMCA – May 21 – June 25 ($90.00)Hanover YMCA – July 9 – Aug 13 ($90.00) East Shore YMCA – April 25 – May 30 ($90.00)East Shore YMCA – July 11 – Aug 15 ($90.00) Carlisle Family YMCA – April 24 – May 29 ($90.00)

Carlisle Family YMCA – July 10 – Aug 14 ($90.00)

York YMCAScuba Diving:

– July 26 ($50.00)

Climbing:Climbing Clinic, Climbnasium – June 14 – Aug 9 ($40.00 each)

ACES:ACES Ages 10 – 22 York – June 2 – June 16 ($40.00)

Bocce Ball: Soldiers and Sailors Memorial Park – June 2 – July 7 ($50.00)Soldiers and Sailors Memorial Park – July 21 – Aug 25 ($50.00)

Respite Programs: Club Lily Respite – Oct 10 – Oct 12 ($330.00)

PB Military Respite East – Oct 17 - Oct 19 (FREE)PB Military Respite West – Oct 31 - Nov 2 (FREE)

ACES Adventure Weekend – Sept 26 – Sept 28 ($225.00)

Locations Vary – Saturdays, May 17, June 21, July 26, and Aug 16, 2014 ($25.00 per month; $100.00 for 4 months)

All-Abilities Social Group

Arts and Crafts: Art for All Capital Area – May 6 – June 10 ($90.00)

Art for All Capital Area – June 24 – July 29 ($90.00)Art for All Capital Area – Aug 12 – Sept 16 ($90.00)

Music and Me:Jan 14 - 18 and March 11 - April 15 ($190 for 6 weeks)Jan 16 - Feb 20 and March 13 - April 17 ($190 for 6 weeks)

Expressions:York Little Theatre – Feb 3 – March 10 ($90.00)

Kayaking Clinic:

Ski Roundtop – June 14, 2014 ($90.00)

P.K. Filling Adapted Water Sports:Lake Aldred – Aug 2 & 3 ($35.00 per lesson, 2 Lessons $50.00)

Sunday LessonSaturday Lesson

1 Lesson 1 Lesson

2 Lessons 2 Lessons

20

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.

21

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.

WEB DESIGN & DEVELOPMENT

YOUR SOURCING PARTNER

400 North Blue Ribbon Avenue, Harrisburg, PA 171121.800.564.7002 • 717.652.3310 | www.higherinfogroup.com

We create operational efficiencies enabling our partners to effectively manage

their information to compete in a changing world.

BUSINESS EQUIPMENT

CORPORATE PRINTING

IT SERVICES

DOCUMENT STORAGE

SHREDDING SERVICES

Printing of this Easter Seals booklet by: Higher Infromation Group

East

er S

eals

Wes

tern

and

Cen

tral P

enns

ylvan

ia25

50 K

ings

ton

Rd. S

uite

219

York

,, PA,

1740

2

Retu

rn S

ervi

ce R

eque

sted

Non-

Prof

it Or

g.U.

S. P

OSTA

GEPA

IDPe

rmit

No. 7

92Yo

rk, P

A, 17

792