METROPOLITAN BOARD OF PARKS & RECREATION
disABILITIES Program Application 2014 / Office Use Only
Date Received:

I hereby make application for ______to participate in planned recreational activities conducted by the Metropolitan Board of Parks & Recreation. I understand that transportation will only be provided for certain designated activities throughout the year. I also understand that the Recreation Staff will provide reasonable supervision, but will not be held liable in the event of an accidental injury.

Parent/Guardian/Self Signature / Date
Full Name:
Birthdate: / Month: / Day: / Year:
Address:
City: / State: / Zip Code:
Telephone: / Home: / Cell: / Email:
Parent/Guardian #1:
Telephone: / Home: / Work: / Cell:
E-mail Address:
Parent/Guardian #2:
Telephone: / Home: / Work: / Cell:
E-mail Address:
LIST THE PRIMARY DISABILITY:
LIST ANY ALLERGIES:
LIST MEDICAL CODES: / A – Allergies C – Coronary/Heart Condition D – Diabetes DS – Down Syndrome
H – Hearing Impairment S – Seizures V – Visual Impairment WC – Wheel Chair
PLEASE MARK ALL PROGRAMS THAT YOU ARE INTERESTED IN:
Monday Program @ Hartman Park / Special Olympics
Monday Program @ Coleman Park / Flag Football
Tuesday Program @ Hartman Park / Soccer
Wednesday Program @ Hartman Park / Bowling
Wednesday Program @ Coleman Park / Alpine Skiing
Thursday Program @ Hartman Park / Snowboarding
Bowling League @ PlaMor Lanes (Tuesdays) / Speed Skating
Adult Summer Program (24+ yo) / Basketball
Young Adult Summer Program (16-24yo) / Bocce
Nature Pals Program (16-24yo) / Aquatics
Family Events / Powerlifting
Best Buddies w/ Vanderbilt / Track & Field
Community Days / Volleyball
Golf
PLEASE MARK T-SHIRT SIZE: S M L XL 2XL 3XL 4XL
Metro Parks’ disABILITIES Office: 862-8479 FAX: 880-3128
Hartman Park Regional Center: 2801 Tucker Road, Nashville, TN 37218
Coleman Park Regional Center: 384 Thompson Lane, Nashville, TN 37211
www.facebook.com/metroparksdisabilities / The Metro Board of Parks & Recreation does not discriminate on the basis of age, race, sex, color, national origin, or disability in admission, access to, or operation of its programs, services, or activities. For TTY (relay service), please call 1-800-849-0299.
éFor questions, concerns, or requests regarding the American Disabilities Act, call 615-862-8400.