MONTGOMERY RELAY

November 2006  Page

TEAM PASA ( Potomac Adaptive Sports Association) is offered in a partnership with Montgomery County Department of Recreation and The Potomac Community Center.

Sundays January 7– March 4th

9:30-11:00

Potomac Community Center 11315 Falls Road

PASA is open to all children with special needs ages 6-14/15.

Special Note* SOMO athletes ages 10-14/15 who wish to train on TEAM PASA and compete in  Saturday round robin games must send in this registration form and $20.00 PASA fee to:

Special Olympics MO  - PO Box 1809 Rockville MD 20849        

Name:________________________________________________       Age_______

School:_______________________________________________    Grade_______

Address:____________________________________________________________

City:______________________________________Zipcode:___________________

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:_______________________________________________________________