Kean University Young Athletes Program - Special Olympics New Jersey

Date: December 5, 2022 Location: Kean University East Campus Gymnasium
215 North Avenue
Hillside, New Jersey 07203 Time: 3:45 pm – 4:30 pm

Date: December 5, 2022

Time: 3:45 pm to 4:30 pm

Come play with us!

Kean University hosts Young Athletes Program

October 24
November 7, 21
December 5
Mondays, 3:45pm-4:30pm

This is an inclusive sports play program for children ages 2-7 with and without intellectual disabilities to develop and improve their social, gross motor and introduction to sports skills. Led by an inter-professional team of Kean University Recreational Therapy and Occupational Therapy students and faculty.

Program Expectations:

All participants must participate with a parent/guardian or caretaker
Must commit to all program dates
- If you cannot attend any session dates, you are responsible for letting the coach know
All participants must wear athletic shoes or sneakers
Registration is required

Campus Information:

East Campus gym (Jacquline Town Court) at Kean University
Park and enter through the back entrance

Ready to PLAY?

Athlete Information

First Name

Last Name

Birthdate (mm/dd/yyyy)

Gender

MaleFemale

Registrant Type:

Athlete Information

Does this Athlete have? (check all that apply)

AutismCerebral PalsyDown SyndromeFetal Alcohol SyndromeFragile X SyndromeUnidentified

Other:

Please Mark Items you would Special Olympics to know:

Requires wheelchair accessibilityMedical conditionSpecial Diet/Allergies

Other:

Parent/Guardian Information

First Name

Last Name

I prefer communication in:

EnglishSpanish

Email Address

Phone Number

Phone Type:

MobileHome

Mailing Address (House #, Street, Apt #)

City

State

Zip Code

Area/County

How did you hear about the Young Athletes Program?

SchoolEarly InterventionInternet/WebsiteFriendOther:

Release Form:

I am the parent or guardian of the Young Athlete named above and agree to the following:

1. Able to Participate. The Young Athlete is able to take part in Special Olympics. I understand there is a risk of injury.

2. Photo Release. Special Olympics organizations may use the Young Athlete’s picture, video, name, voice and words to promote Special Olympics.

3. Emergency Care: If a medical emergency should arise during the Young Athlete’s participation in Special Olympics activities at a time when a parent or guardian is not present to make medical decisions, I consent to medical care for the Young Athlete if needed, unless I check one of these boxes:

I have a religious or other objection to the Young Athlete receiving medical treatment.

I consent to emergency medical care, but I do not consent to blood transfusion for the Young Athlete.

(If either box is checked, an EMERGENCY MEDICAL CARE REFUSAL form will be sent and MUST be completed)

4. Health Programs. If the Young Athlete takes part in a Special Olympics health program, I consent to health activities, exams and treatment for the Young Athlete. This should not replace regular health care. I can say no to treatment or anything else at any time for the Young Athlete.

5. Personal Information. I understand personal information may be used and shared by Special Olympics to:

Make sure Young Athletes can participate safely;
Run training and events and share results;
Put the Young Athletes information in a computer system;
Provide health treatment, make referrals, consult doctors, and remind me about follow-up services;
Research, share and respond to needs of the Special Olympics participants (identifying information removed if shared publicly); and
Protect health and safety, respond to government requests, and report information required by law.
I can ask to see and change the Young Athlete’s information. I can ask to limit how the information is used.

6. Concussions. I understand there is a risk of concussions and continuing to play sports with a concussion. The Young Athlete may have to get medical care if a concussion is suspected. The Young Athlete may also have to wait 7 days or more and get permission from a doctor before he/she starts playing sports again.

I am the parent/guardian of the participant named on this registration form. I have read and fully understand the provisions of the above release. Through my signature on this release form, I am agreeing to the above provisions on my own behalf and on the behalf of the participant named above to participate in Special Olympics games, recreation programs and physical activity programs.

Parent/Guardian Signature

Date

Communicable Diseases Waiver

Waiver and Release of Liability, Assumption of Risk and Indemnification Agreement for Communicable Diseases ("Agreement") for Special Olympics New Jersey

In consideration of being allowed to participate in any way in Special Olympics sports training, competition or fundraising activities, the undersigned acknowledges, appreciates, and agrees that:

Participation includes possible exposure to and illness from infectious and/or communicable diseases including but not limited to MRSA, influenza, and COVID-19. While particular rules and personal discipline may reduce this risk, the risk of serious illness and death does exist; and,

I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES or others, and assume full responsibility for my participation; and,

I willingly agree to comply with the stated and customary terms and conditions for participation as regards protection against infectious diseases. If, however, I observe and any unusual or significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the nearest official immediately; and,

I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE AND HOLD HARMLESS Special Olympics, Inc, Special Olympics New Jersey, their officers, officials, agents, and/or employees, other participants, sponsoring agencies, sponsors, advertisers, and if applicable, owners and lessors of premises used to conduct the event ("RELEASEES"), WITH RESPECT TO ANY AND ALL ILLNESS, DISABILITY, DEATH, or loss or damage to person or property, WHETHER ARISING FROM THE NEGLIGENCE OF RELEASEES OR OTHERWISE, to the fullest extent permitted by law.

Signature Type

Parent/ Guardian Signature (Required for participant who is a minor (younger than age 18) or lacks capacity to sign documents.)

Parent/Guardian Signature

For participants of minority age (under age 18 at the time of registration) or those over 18 without the capacity to sign for themselves.

This is to certify that I, as parent/guardian with legal responsibility for this participant, have read and explained the provisions in this waiver/release to my child/ward including the risks of presence and participation and his/her personal responsibilities for adhering to the rules and regulations for protection against communicable diseases. Furthermore, my child/ward understands and accepts these risks and responsibilities. I for myself, my spouse, and child/ward do consent and agree to indemnify and hold harmless the Releases for any and all liabilities incident to my minor child's/ward's presence or participation in these activities as provided above, EVEN IF ARISING FROM THEIR NEGLIGENCE, to the fullest extent provided by law.

Parent/Guardian Signature

(By signing this Communicable Diseases Waiver electronically, you agree your electronic signature is the legal equivalent of your manual signature.)

Today's Date (MM/DD/YYYY)

Relationship

RELEASE AND WAIVER OF LIABILITY FORM

Participant Full Name

I wish to participate in the Special Olympics New Jersey Young Athlete’s Program (“Program”) being held on October 24, November 7, 21, and December 5 at Kean University, 1000 Morris Avenue, Union, New Jersey. I understand and appreciate the dangers, hazards and risks inherent in my participation in the Program and voluntarily assume all such dangers, hazards and risks, including those that may result in injury to myself or my property.I agree that neither Kean University, the State of New Jersey and any trustee, director, officer, agent, employee, member, volunteer or any other representative of Kean University, the State of New Jersey, nor any of their respective successors or assigns (collectively, “Kean”) shall be liable for any loss, damage, injury (including death) or claim of any kind to person or property arising from or caused by my participation in the Program, including without limitation, any loss, damage or claim arising from an accident, injury or casualty involving me whether or not on or off Kean’s property. I further agree to indemnify, defend and hold harmless Kean from all loss, liability, damages, claims, costs and expenses (including court costs and actual attorney’s fees) arising from or related to same. I further agree to abide by Kean’s rules, regulations and directives governing the use of Kean’s facilities. This Release and Waiver is intended to be as broad and as inclusive as permitted by the laws of the State of New Jersey. If any portion of the Release and Waiver is declared invalid, I agree that the remainder of the Release and Waiver will continue to be applicable. This Release and Waiver is binding on my heirs, spouse, parents, guardians, executors, administrators and/or assigns.I am at least eighteen (18) years of age, or, if not, have secured below the signature of my parent or guardian, as well as my own, and am fully competent to sign this Release and Waiver. I execute this Release and Waiver for full, adequate, and complete consideration, fully intending to be bound by the same, and I will be responsible to pay any medical costs that may occur as a result of any illness or injury to me. If illness or injury should occur during my participation in the Program, I authorize Kean to provide medical treatment at an appropriate medical facility. I will not hold Kean, its employees and agents responsible for the kind and quality of emergency medical treatment received by me.

I further consent to and authorize Kean University, its officers, agents, employees and assigns to:

a) Record my likeness and voice on a video, audio, photographic, digital, electronic, print, and any other medium.
b) Use my name in connection with these recordings.
c) Use, reproduce, exhibit, and distribute in any medium (e.g. print or web publications, productions, news releases) these recordings for any purpose that Kean and its representatives deem appropriate, including promotional or advertising efforts.

I release Kean and its representatives from liability for any violation of any personal, privacy, or proprietary right I may have in connection with such use. I understand that all such recordings, in whatever medium, shall remain the property of Kean. I waive the right to inspect or approve the finished product in which my likeness appears and I acknowledge that no monetary consideration is being paid to me for my appearance, likeness, statements or recordings.

In signing this Release and Waiver, I acknowledge and represent that I have carefully read same, that I understand its contents, and that I sign this document of my own free will. I am aware that important rights are being released and given up.

Participant Full Name

Today's Date (MM/DD/YYYY)

Signature Type

Parent/ Guardian Signature (Required for participant who is a minor (younger than age 18) or lacks capacity to sign documents.)

Parent/Guardian Signature

I certify that I am the parent or legal guardian of the above participant, that I have read the foregoing Release and Waiver. I join in each and every part of the Release and Waiver (including such parts as may subject me to personal financial responsibility for the participant), and release any claim that I may have against Kean, both on my own behalf and in my capacity as legal representative of the participant, including without limitation any claim arising as a result of the participant’s leaving the supervision of Kean.

Parent/Guardian Signature

Today's Date (MM/DD/YYYY)

Contact Information