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MONTGOMERY RELAY
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TEAM PASA ( Potomac Adaptive Sports Association) is offered in a partnership with Montgomery County Department of Recreation and The Potomac Community Center. Sundays April 15—June 3 9:30—11:00 Potomac Community Center 11315 Falls Road Potomac PASA is open to all children with special needs ages 6-15. Mail competed form and PASA fee to: Special Olympics MO - PO Box 1809 Rockville MD 20849 |
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Name:________________________________________________ Age_______ School:_______________________________________________ Grade_______ Address:____________________________________________________________ City:______________________________________Zip code:___________________ Home Phone:_______________________ Family cell phone:__________________ Family email: _________________________________@______________________ Emergency Contact:___________________________________________________ Phone:___________________________Cell Phone___________________________ Description of disability / special needs :___________________________________ _____________________________________________________________________ Have you played on Team PASA in past seasons? Yes no
The County and P.A.S.A. assume no liability for injury and damages arising from participation in this program. All activities present inherent risks and hazards which the participant assumes. I hereby accept any risk associated with participation in this program. To the best of my knowledge there are no physical or other conditions which will interfere with my child’s participation. I hereby approve my child’s participation in this program and consent to emergency medical treatment for my child on my behalf. I understand that the photographs taken of Recreation Programs may be used by Montgomery County Department of Recreation. Signature:________________________________________________________________Date__________________ Print Name:_______________________________________________________________ |
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February 2007 Page 7 RELAY |
