* - Required field
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Regional Center Client
* Please indicate program and location applying for
* First Name
* Last Name
* Address 1
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District of Columbia
* Zip Code
* Date of Birth
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* Primary Language at Home
If other, please list
Alternate E-mail address
* Home Phone
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* Parent/Guardian First Name
* Parent/Guardian Last Name
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* Primary Parent/Guardian Home Phone
Primary Parent/Guardian Work Phone
Primary Parent/Guardian Cell Phone
Parent/Guardian First Name
Parent/Guardian Last Name
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Secondary Parent/Guardian Work Phone
Secondary Parent/Guardian Work Phone ext.
Emegency Contact 1
Emergency Contact 2
The Athlete Profile
In order to provide the best experience for your child and their volunteer coach, KEEN provides the coach with a profile of your child, which gives them basic information such as their disability, good approaches to use when working with them, things to avoid, etc. Please be as detailed as possible when completing this section.
If Other, please describe diagnosis
* Self-Injurious Behavior
* Temper Tantrums
* Running Away
Please describe all behavior problems
* Communication Style
If other, please describe communication style
* Ability to Understand Verbal Communication
If needed, please describe verbal communication
* Hand and arm use
* Toileting skills
Not toilet trained
Goes to toilet by self
If other, please describe toileting skills
* Attention Span Time
30 minutes & more
* Interact with Peers
* Interact with Adults
* Adjust to changes in physical environment
* Adjust to changes in social environment
* Participate in social and group activities
* Athelete Demonstrates Safety Awareness
* Repetitive Body Movement
* Visual Perception
* Special Equipment Used
Assists in moving
Describe other special equipment
* Helpful Hints for working with my child
* Child's favorite activities
* Target Areas to work on
* What you hope your child will gain
* Swim efficiently?
* Swim with life jacket?
* Swimming lessons?
* Swim deep water?
* Swim with pull-ups?
* Swim comments
Consent and Release and Publicity Waiver
In consideration of the opportunity to participate in events or activities that are organized or coordinated by Kids Enjoy Exercise Now USA (“KEEN”) or one of its local affiliates, subsidiaries or agents (“Affiliates”), including sports and recreational activities (each, an “Event”):
1. I, the undersigned, on behalf of myself and my children for whom I am the parent or legal guardian authorized to act on their behalf (collectively “Children” and each a “Child”) (together, me and them, the “Participants”), and on behalf of my and my Children's heirs, estates, insurers and assigns, agree that KEEN and its Affiliates shall not be responsible or liable for, and irrevocably release and discharge KEEN and its Affiliates, and their officers, directors, employees, agents and volunteers, from any claims or liability of any kind arising from any losses, damages or injuries (including death) to persons or property of any kind resulting, in whole or in part, directly or indirectly, from attendance at or participation in any Event, including without limitation, during travel or transportation to or from an Event whether by transportation provided by KEEN or its Affiliates or any other means.
2. I, the undersigned, do hereby consent, agree and give permission to KEEN and its Affiliates, and their officers, directors, employees, agents and volunteers, to take photographs and make, videotape, audiotape or digital recordings of the Participants at the Event and to use, reproduce, exhibit, publish and otherwise exploit the Participants' likenesses, names, voices, statements, personal stories and biographies (collectively, “Likeness”), alone or with others, in any and all media, now or hereafter known, throughout the world in perpetuity for promotional, publicity, training and similar purposes. The Likeness may be altered or modified in KEEN's and/or its Affiliates' sole discretion. I waive any opportunity or right to inspect or approve any such use or exploitation of the Likeness on behalf of the Participants. I agree that all materials created by or for KEEN and/or its Affiliates are the sole property of KEEN or its Affiliates (as relevant), including all copyrights therein. To the extent any Likeness may contain any matter subject to copyright protection in which a Participant claims rights, I, on behalf of the Participants, hereby assign to KEEN and its Affiliates all right, title and interest, including copyright, in such matter in any and all media, now or hereafter known, throughout the world in perpetuity.
3. I, on behalf of the Participants and on behalf of my and my Children's heirs, estates, insurers and assigns, irrevocably release and discharge KEEN and its Affiliates, and their officers, directors, employees, agents and volunteers, from any claims or liability of any kind arising from the making, use, reproduction, publication, marketing or other exploitation of the Likeness, and any alteration or compilation thereof. I waive any rights, claims, or interest that the Participants may have to control the use of the Likeness in any manner or in whatever media used. I understand that there will be no financial or other remuneration to the Participants for creating or exploiting the Likeness.
4. Regarding the releases granted herein, I expressly waive California Civil Code § 1542, or any other statute of similar import or effect, that otherwise may exclude unknown claims from this release. I acknowledge that I am familiar with the provisions of California Civil Code § 1542, which provides as follows: “A GENERAL RELEASE DOES NOT EXTEND TO CLAIMS WHICH THE CREDITOR DOES NOT KNOW OR SUSPECT TO EXIST IN HIS OR HER FAVOR AT THE TIME OF EXECUTING THE RELEASE, WHICH IF KNOWN BY HIM OR HER MUST HAVE MATERIALLY AFFECTED HIS OR HER SETTLEMENT WITH THE DEBTOR.” Being aware of said code section, I hereby expressly waive any rights I may have thereunder, as well as any other statute or common law principles of similar effect.
5. I, on behalf of the Participants and on behalf of my and my Children's heirs, estates, insurers and assigns, will indemnify and hold harmless KEEN and its Affiliates, and their officers, directors, employees, agents and volunteers, from and against any losses, actions, claims, damages, or expenses of any kind, including without limitation attorneys' fees and costs, which may be incurred by or asserted against or by any of them, by any Participant or any third party, arising from or relating to (i) the making, use, publication, marketing or other exploitation of the Likeness in any manner whatsoever; or (ii) any losses, damages or injuries to persons or property of any kind resulting, in whole or in part, directly or indirectly, from attendance at or participation in an Event, including without limitation during travel or transportation to and/or from an Event by any means. This indemnity and obligation to defend and hold harmless shall survive any termination of this Release or the parties' activities hereunder.
6. I represent that I am at least 18 years of age, have read and understand the foregoing Consent and Release, and am competent to execute this Consent and Release, and that I am the parent or legal guardian authorized to act on behalf of each Child listed below.
I have read and understand the above Consent and Release and Publicity Waiver, and agree to be bound by its terms. My click in the box below signifies my agreement to the Consent and Release and Publicity Waiver.
* I agree to the Consent and Release and Publicity Waiver
Number in Household
I represent that I am the parent or legal guardian authorized to act on behalf of the applicant and any siblings listed above with the right to grant the consent, release, waiver and indemnity granted herein on behalf of the applicant and any siblings listed above.
I have read and understand the above representation concerning the Consent and Release and Publicity Waiver. My click in the box below signifies my agreement to the Consent and Release and Publicity Waiver on behalf of my Child or Children.
* I agree to the Consent and Release and Publicity Waiver on behalf of my Child or Children.
* Relationship to Child