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*Application Update is good for 2 years from today’s date if you have a full application on file with STRIDE office

v Demographic Information TODAYS DATE_________

Participant's name: ______________________________________________ Age: ___________ D.O.B.: ______________

Parents/guardian: _____________________________________________________________________________________

Address: __________________________________________City/State: __________________________Zip: ___________

Phone: ____________________ Emergency phone: _______________________Work phone____________________

E-mail address: _______________________________________Cell Phone__________________________________

v Education and general disability information

Disability classification: __________________________ Educational level: ______ Communication: poor fair good

Personal Data: Height:______ Weight: ______ General Physical Condition:_______ Shoe size__________

v Please list changes to Participant diagnosis or behavior within the past 12 months:

v Please list changes (e.g.: wheelchairs, splints, walk aids, swim aids, etc.) within the past 12 months:

v Please list any changes or additions in medication within the past 12 months:

v I am aware of my responsibility to notify STRIDE of any material changes to medical health, medicines or overall health and well being of my STRIDE participant prior to acceptance in a program.

Signature: __________________________________________________ Date: ____________

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Yes___________ No_________ Not at this time, please ask again at another time____________________

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v Cancellation Policy For Programs

STRIDE must keep on file a valid Credit Card # in the event that participants with reservations for programs do not follow cancellation protocols .

Credit Card #: __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ Card: VISA MC Exp. Date: ___________

STRIDE, Inc / and DS/USA INSURANCE WAIVER & RELEASE OF LIABILITY FORM and MEDIA RELEASE FORM

In consideration of being allowed to participate in any way in STRIDE Inc. and/or DISABLED SPORTS USA’s programs, related events, and activities, I and/or the minor participant, for myself, and on behalf of my heirs, assigns, personal representatives and next of kin, the undersigned:

1. Agree that prior to participating, I will inspect, or if a parent and/or legal guardian I will instruct the minor participant to inspect, the facilities and equipment to be used, and if I believe, to the best of my ability, that anything is unsafe, I and/or the minor participant will immediately advise STRIDE, Inc. and/or DISABLED SPORTS USA of such condition(s) and refuse to participate.

2. Acknowledge and fully understand that I and/or the minor participant, will be engaging in activities that involve risk of serious injury, including permanent disability and death, and severe social and economic losses which might result only from my own actions, inactions or negligence of others, the rules of play, or the condition of the premises or any equipment used. Further, that there may be other risks not known to me or not reasonably foreseeable at this time.

3. Assume all the foregoing risks and accept personal responsibility for the damages following such injury, permanent disability or death.

4. Release, waive, discharge and covenant not to sue STRIDE, Inc. and/or DISABLED SPORTS USA, its affiliated clubs, their representative administrators, directors, agents, coaches, and other employees of the organization, other participants, sponsoring agencies, sponsors, advertisers, their heirs, and if applicable, owners and leasers of premises used to conduct the event, all of which are hereinafter referred to as "releasees", from demands, losses or damages on account of injury, including death or damage to property, caused or alleged to be caused in whole or in part by the negligence of the releasee or otherwise.

I/WE HAVE READ THE ABOVE WAIVER AND RELEASE, UNDERSTAND THAT I/WE HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, HAVE NOT CHANGED IT ORALLY, AND SIGN IT VOLUNTARILY.

X_____________________________________________________________________________

Participant's Name (PLEASE PRINT CLEARLY) Signature Date

This is to certify that I, as parent/guardian with legal responsibility for this participant, do consent and agree to his/her release as provided above of the Releasees, and, for myself, my heirs, assigns, and next of kin, I release and agree to indemnify and hold harmless the Releasees from any and all liabilities incident to my minor child's involvement or participation in these programs as provided above, EVEN IF ARISING FROM THEIR NEGLIGENCE.

MEDIA RELEASE FORM

Name_____________________________________________Age________ Male____ Female____

MEDIA/PHOTO WAIVER: I hereby authorize and give my full consent to STRIDE, Inc. and/or Disabled Sports USA to copyright and/or publish any and all photographs, videotapes and/or film in which I appear while attending this STRIDE Inc. and/or DS/USA event. I further agree that STRIDE, Inc. and/or DS/USA may transfer, use or cause to be used, these photographs, videotapes, or films for any exhibitions, public displays, publications, commercials, art and advertising purposes, and television programs without limitations or reservations.