Experience Fitness Project Registration Form

EXPERIENCE FITNESS PROJECT REGISTRATION FORM

Email completed form to

Athlete information

First name: / Last: / Date:
Medical Diagnosis: / Age: / T-Shirt Size (circle one):
S M L XL YS YM YL
Address: / City/ State: / Zip code: / Height:
Does this athlete require volunteer assistance to participate? If yes, please describe what assistance they may need: (please circle one) No / Yes
I am interested in participating in organized race events & activities during this time: /  11:00am- 12:30pm /  12:30pm - 2:00pm
100 M Run/Walk/Roll Event
(please check all that apply): /  I require hand-held assistance
 I have a walker
 I have a manual wheelchair and can propel myself
 I have a manual wheelchair propelled by others
 I have a power wheelchair
 Other:______
 I do not plan to participate in this event
Bike Riding and Races
(please check all that apply): /  I would like to participate in the Bike Races

I have my own bike and helmet and will bring them
I can ride a bike but need to borrow one from Outdoors for All*

 I would like to participate in the bike trial (riding on the track)

I have my own bike and helmet and will bring them
I can ride a bike but need to borrow one from Outdoors for All*

 I have never ridden a bike/tricycle/adapted bicycle before, but would like to participate in the Bike Demo and/or Trial**
 I have interest in using/trying the following type(s) of bikes:

Tandem or side by side bike w/ parent/caregiver
Foot pedal upright bike
Foot pedal tricycle
Recumbent bike
Hand pedal bike
No preference or request

 I do not plan to participate in any bike activities

parent/guardian information

Name: / Date: / Email Address:
Is there any additional information our staff should know about the athlete participating?

LIability and signature

* Any athlete borrowing a bike from Outdoors for All will need to complete a pre-race safety check.
**Efforts will be made to have sufficient equipment on hand for all requests, but availability
will be managed on a first come, first served basis.

PARTICIPANT RELEASE OF LIABILITY – I understand that the above registered participant is taking part in an activity that may be hazardous for the participant. In signing below, I assume risk of harm or injury which may occur to the participant as a result of participating in the Experience Fitness Project. I hereby release Life Enrichment Options, Waypoint Pediatric Therapies and Issaquah High School and its officers, volunteers, employees or agents from liability, costs and damages resulting from this individual’s participation. The participant has my consent to participate in the Experience Fitness Project and related activities. I also give my consent to have photos/videos taken, without recompense, during the races and activities and used for publicity purpose in printed or web format.

Signature of Parent/Guardian Date