WSSRA Registration & Policies - Enriching lives through recreation CHECK OUT OUR IN-PERSON SPECIAL EVENTS ON PAGE 13!
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WSSRA Registration & Policies
WINTER 2021
HABLAMOS
ESPAÑOL
WSSRA
Enriching lives through recreation
CHECK OUT OUR IN-PERSON SPECIAL EVENTS ON PAGE 13!
COVID-19 Guidelines
for WSSRA in-person
How to Register Online
programs
Be considerate of others and
help stop the spread of Step 4. On the registration tab,
COVID-19. select an activity that you would
like to enroll in - it will be added to
Please follow these easy your shopping cart.
steps when you participate
in this winter’s
WSSRA programs. Step 5. Once you select the
Thank you for activity be sure to select the
your cooperation. Step 1. Go to WSSRA.net and correct name of the registrant.
click on the Register tab
Wash your hands
upon arrival at
Step 6. Check out items in your
the program Step 2. Create an account Shopping Cart.
Step 3. Add participants to For help with creating an
your Account that you would like to account or registering for
Practice Social enroll in programs or activities. programs, please call
Distancing Don’t forget to include yourself as the WSSRA office at
Stay 6 feet the Primary Account Holder. 847-455-2100.
away from
others
Wear a face
covering when WSSRA Just visit
indoors and
wants your wssra.net
cannot keep a and click on
6-foot distance feedback! “tell us what
you think!”
Use readily We want your
feedback and suggestions
available regarding the programs for
hand which you have registered.
sanitizers Please take 3-4 minutes to
help us improve the services
we offer. All answers are Thanks
anonymous, confidential, and for your
will be used only by WSSRA.
assistance!
Stay home if
you are sick
Table of Contents For more program information please contact....
WINTER CALENDAR.............................................7
IMAGINARIUM....................................................8 Sylvia Dobbins
LEKOTEK...............................................................9 Social Clubs & Young Adults
IN-PERSON PROGRAM GUIDELINES.................. 10
IN-PERSON CHILDREN & YOUTH PROGRAMS... 11
IN-PERSON TEEN & ADULT PROGRAMS............ 12
IN-PERSON SPECIAL EVENTS............................. 13
VIRTUAL PROGRAM INFORMATION................. 14
VIRTUAL ALL AGES PROGRAMS................... 15-16 Mia Leyba
VIRTUAL SPECIAL EVENTS................................. 16 Teens & After School Programs
Inclusion Support
VIRTUAL ALL TEENS & ADULTS PROGRAMS.17-18
VIRTUAL CHATS.................................................. 19
SPECIAL OLYMPICS GUIDELINES....................... 20
Key to Abbreviations
ADD Attention Deficit Disorder
ADHD Attention Deficit Hyperactivity Disorder Kelly Baran
ALZ Alzheimer’s Swim programs, Adults
AUT Autism
DD Developmental Disability
EC Early Childhood
ED Emotional Disturbance
HI Hearing Impairment
LD Learning Disability
MI Mental Impairment
MH Multiple Handicaps
MLH Mental Health
Christina Fernandez
PI Physical Impairment Children & Youth,
SL Speech and Language Delay Imaginarium Sensory Room
SO Special Olympics
SP Severe and Profound Mental Impairment
VI Visual Impairment
Our Program Guide Chris Sturm
A great effort has been made to assure the accuracy of the
information provided in our Program Guide. Due to the large Special Olympics
amount of information, however, errors and changes may Inclusion Support
occur related to program schedules, locations, transportation
and fees.
WSSRA reserves the right to make adjustments as necessary.
WSSRA will make every effort to notify participants of changes
and corrections as quickly and efficiently as possible.
We apologize for any inconvenience our errors may cause. Carlos Marroquin
Day Camp
West Suburban Special
Recreation Association
2915 maple street
franklin park, il 60131 office hours
847.455.2100 - voice or tty monday through friday 8:30 am – 5:00 pm
Who We Are
The West Suburban Special Recreation Association is part of your local park district or village recreation
department. We provide recreation programs for individuals who have any type of disability.
Your park district or village governs the operation of the Association.
WSSRA Staff
Marianne Birko......................226.................. executive director ...................................................... marianneb@wssra.net
Annie Hart............................230.................. superintendent of safety & operations ........................... annieh@wssra.net
April Ryan............................. 231................... superintendent of recreation..............................................aprilr@wssra.net
Carla Pakenas....................... 219................... staff manager .................................................................... carlap@wssra.net
Carlos Marroquin..................232.................. program manager ............................................................ carlosm@wssra.net
Christopher Sturm................ 235.................. inclusion manager .............................................................. chriss@wssra.net
Nicole Walsh.........................240.................. public relations coordinator ..........................................nicolew@wssra.net
Kelly Baran............................ 239.................. recreation specialist .......................................................... kellyb@wssra.net
Mia Leyba.............................. 236.................. recreation specialist .............................................................mial@wssra.net
Sylvia Dobbins...................... 238.................. recreation specialist ....................................................... sylviad@wssra.net
Christina Fernandez.............234.................. recreation specialist ....................................................christinaf@wssra.net
Lisa Gershak......................... 221................... finance manager....................................................................lisag@wssra.net
Noelia Hernandez.................222.................. registrar...............................................................................nolyh@wssra.net
Antonio Casas.............................................. receptionist......................................................................... tonyc@wssra.net
Julie Clasen.................................................. school liason........................................................................juliec@wssra.net
Julia Harmon Bell.................224.................. fund development specialist/lekotek leader.....................juliab@wssra.net
Luz Rocha-Serrano...............224.................. lekotek leader........................................................................ luzs@wssra.net
Keiajah Barber.............................................. wssra driver
Mike Zych...................................................... wssra driver
Frank Quaranta............................................. wssra driver West Suburban
Board of Directors Special Recreation
BERWYN PARK DISTRICT ..................................SANDY FEJT
VILLAGE OF ELMWOOD PARK............................ AL SCHMIDT
Foundation
PARK DISTRICT OF FOREST PARK............. JACKIE IOVINELLI The West Suburban Special Recreation
PARK DISTRICT OF FRANKLIN PARK......... JOSEPH MODRICH Foundation (WSSRF) is an Illinois
not-for-profit corporation that exists to raise funds for
VILLAGE OF HARWOOD HEIGHTS............... ANNA WEGRECKI
WSSRA. The funds raised by the WSSRF help expand
NORRIDGE PARK DISTRICT..............ANNEMARIE FLAHERTY
programming and support additional needs of WSSRA when
NORTH BERWYN PARK DISTRICT................... MARK SLADEK necessary. To learn more about WSSRF, call Marianne Birko
PARK DISTRICT OF OAK PARK....................KASSIE PORRECA at the WSSRA office. The WSSRF needs you!
RIVER FOREST PARK DISTRICT...................... MIKE SLETTEN
VILLAGE OF NORTH RIVERSIDE...................TERESA MROZIK New Members
VILLAGE OF RIVERSIDE.............................. RON MALCHIODI The WSSRF welcomes new members. Please consider joining!
VETERANS PARK DISTRICT....... CARLENE BUVAK GREIFELT No one on the Foundation is asked to do more than they can
handle, yet by working together, WSSRF raises $40,000 each
Board Meetings year to support WSSRA programs. At each meeting,
Foundation members have the opportunity to give input and
The Board of Directors of the Association meets on
the second Tuesday of the month, 8 times per year at ideas about program offerings. So come join the fun and help
4:00pm. Call the office for a meeting schedule and WSSRF improve and expand programs for persons of all ages
locations. The public is invited to attend. with disabilities.
4
Facilities
BENSENVILLE HARWOOD HEIGHTS Rehm Park
515 Garfield St........................ 708.848.9661
White Pines Golf Course Harwood Heights Village Hall
Ridgeland Commons Rec Complex
500 W. Jefferson St................. 630.766.0304 7300 Wilson Ave .................... 708.867.7200
415 Lake St............................. 708.725.2300
BERWYN MELROSE PARK Stevenson Recreation Center
49 Lake St............................... 708.725.2300
Havlicek School Bulger Park Community Center
West Cook YMCA
6401 15th St........................... 708.795.2450 1601 Hirsch St......................... 708.731.5290
255 S Marion St #3103........... 708.383.5200
Jefferson School George A. Leoni Complex
Whittier School
7035 16th St........................... 708.795.2454 800 N. 17th Ave...................... 708.716.4822
715 N Harvey Ave................... 708.524.3080
Liberty Recreation Center Michael Cimbalo Fitness Center and Museum
6445 W 27th Pl....................... 708.795.2891 1203 N. 24th Ave.................... 708.343.5151 RIVER FOREST
Morton West High School
NORRIDGE Keystone Center
2400 Home Ave...................... 708.222.5700
North Berwyn Park District Community Center Leigh School 7920 Central Avenue.............. 708.366.6660
1619 Wesley Ave ................... 708.749.4900 8151 W. Lawrence Ave........... 708.456.8848
Norridge Park District
RIVER GROVE
PAV Berwyn YMCA
2947 S Oak Park Ave............... 708.749.0606 4631 N Overhill Ave................ 708.457.1244 Trumbull Park
Proksa Park 2311 N. Leyden ...................... 708.731.5290
NORTHLAKE
3001 Wisconsin Ave............... 708.795.2892
Grant Park Recreation Center RIVERSIDE
ELMWOOD PARK 44 W. Golfview Drive.............. 708.343.5270 Historic Water Tower
Centennial Park 10 Pine Avenue....................... 708.442.7025
7600 W Armitage Ave............. 708.452.3935
NORTH RIVERSIDE
Riverside Swim Club
Elmwood Park Recreation Center Komarek School 100 Bloomingbank Rd............ 708.447.6134
2 Conti Pkwy........................... 708.452.3935 8940 W 24th St....................... 708.447.8030
Elmwood Park Family Aquatic Center North Riverside Community Room EMERG EN CY PH ON E
2 Conti Pkwy........................... 708.452.3935 2359 S. DesPlaines Ave........... 708.442.5515
Elmwood Park High School The purpose of
8201 W Fullerton Ave............. 708.452.7272 OAK PARK this phone number
Andersen Center is to allow access
FOREST PARK
820 Hayes Ave ....................... 708.725.2000 to WSSRA for
Circle Lanes
7244 Circle Ave ...................... 708.366.2810
Barrie Recreation Center emergencies only during
1011 S Lombard Ave .............. 708.725.2000 non-office hours.
Field Stevenson School Carroll Recreation Center
925 Beloit Ave ....................... 708.366.5703 1125 S Kenilworth Ave........... 708.725.2000
Park District of Forest Park 1. The phone may be called
Cheney Mansion
7501 Harrison St .................... 708.366.7500 220 N Euclid Ave..................... 708.725.2500
Monday through Friday, from
Forest Park Middle School Dole Center 5:00pm to 11:00pm, Saturday,
925 Beloit Ave ....................... 708.366.5703 255 Augusta St ....................... 708.725.2000 7:00am to 11:00pm when
Grant White School
147 Circle Ave ........................ 708.366.5704
Dynamic Lynks programs are in session only.
1100 Lake St #LL65 ................708-620-2373
Roos Recreation Center Field Recreation Center
7329 Harrison St .................... 708.366.7500 935 Woodbine Ave ................ 708.725.2000
2. Leave a message with your
FRANKLIN PARK Fox Recreation Center phone number at 708.491.3779
624 S Oak Park Ave................. 708.725.2000 and a WSSRA staff will return your
Centre at North Park
10040 Addison St................... 847.928.8478
Gymnastics & Recreation Center (GRC) call if necessary.
21 Lake St .............................. 708.725.2000
Franklin Park Community Center
Imaginarium Sensory Room
9560 Franklin Ave .................. 847.455.2852
228 Madison........................... 847.455.2100
3. The emergency phone should not
Franklin Park Ice Arena be a substitute for calling the office
Irving School
9711 Waveland Ave ............... 847.671.4268
1125 S Cuyler Ave .................. 708.524.3090 for non-emergency questions, such
Franklin Towers
9535 Franklin Ave .................. 847.455.0189
Longfellow Recreation Center as pick up times.
610 S Ridgeland Ave .............. 708.725.2000
Gouin Park Pool and Water Slide
Longfellow School
2400 Scott St .......................... 847.451.9396
715 S Highland Ave................. 708.524.3060
Pool on Pacific
9715 Pacific Ave ..................... 847.455.2858
Oak Park Conservatory WWW.WSSRA.NET
615 Garfield St........................ 708.725.2400 Check out WSSRA on the web for
O'Hare CrossFit
Oak Park Country Club
9100 Belden Ave .................... 708.417.8502 directions to program locations and
2001 Thatcher Ave................. 708.453.5554
WSSRA Office
Oak Park River Forest High School
up to date program information.
2915 Maple St........................ 847.455.2100
201 N Scoville Ave ................. 708.383.0700 Email your comments to us:
wssra@wssra.net
5
Staff Spotlight
Top Row L-R: Christopher Sturm, Inclusion Manager; Carla Pakenas, Staff Manager; Mia Leyba, Recreation Specialist
Second Row L-R: Carlos Marroquin, Program Manager; Kelly Baran, Recreation Specialist; Sylvia Dobbins, Recreation Specialist
Bottom Row: Christina Fernandez, Recreation Specialist
Cheers to our incredible Recreation Team for
providing innovative and creative virtual and
in-person program opportunities for WSSRA
participants and families. Thank you for making
us laugh and putting a smile on our faces during
these most challenging times.
6
Winter 2021 Program Calendar
FEBRUARY 1 - March 27
SPECIAL
MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY
EVENTS
VIRTUAL MINDFUL WALK & TALK WINNER TAKES ALL* HEALTHY START VIRTUAL CREATIVE CARDIO
MASTER CHEF MORNINGS 10:15-11:15am 10:00-11:00am 10:30-11:00am ADVENTURES 9:45am-10:15am
January 22 10:30-11:00am Village of Elmwood Park 10:30-11:00am
5:30-6:30pm Harwood Heights Recreation Center/
2/2, 2/9, 2/16, 2/23 Virtual BINGO
SIBSHOPS
Leoni Complex, 2/11, 2/25, 3/11, 3/25
BOBCATS ROAR URBANITES Melrose Park 11:00-12:00pm RHYTHMIC 1/9, 1/23, 2/13,
Information Meeting EPHS STUDENTS 3/2, 3/9, 3/16, 3/23 HOME DESIGN TIME Grant Park, GYMNASTICS & 2/27, 3/13, 3/27
January 30 11:00-11:30am 4:30-5:15pm Northlake MOVEMENT 10:00am-12:00pm
6:15-6:45pm No Program 2/15 5:00-6:00pm Proksa Park, Berwyn
Will meet 1x/month MORNING MIXER Liberty Center, Berwyn
EXPLORE THE ARTS* 10:30-11:00am DANCE YOGA AFTERSCHOOL
VIRTUAL VALENTINE’S TBD/Virtual 6:00-6:45pm ADVENTURES WINTER
DAY DANCE 6:00-7:00pm Andersen Center, 4:30-5:00pm FOOD CRITICS WANDERINGS
YOGA Oak Park
February 13 6:00-6:30pm 2/6, 2/20, 3/6
4:30-5:00pm
7:00-8:00pm POWERLIFTING MUSIC MAKERS Time Varies
MONDAY NIGHT 6:30-7:30pm 5:30-6:15pm Carroll Center, Oak Park
FAMILY SKATE SPORTS TALK BOBCATS O’Hare CrossFit SHOWTIME
February 19 6:30-7:00pm SKILLS & DRILLS 6:00-6:30pm
6:45- 7:30pm 7:00-8:00pm SOCIALITES DICE BOWLING
7:30- 8:15pm Franklin Park LET’S DANCE 2/4, 2/18, 3/4, 3/18 10:30-11:15am
Ridgeland Commons WEEKLY WORKOUT Community Center 6:15-7:00pm 6:30-8:00pm TGIF
7:15-7:45pm Trumbull Park, 2/12, 2/26, 3/12
HIPPITY HOPPITY River Grove 7:00-8:30pm SATURDAY
HUNT Park District of Forest BOWLING
10:00-11:00am VIRTUAL THEATRE Park, Building #4 LEAGUE
11:30am-12:30pm 6:45-7:30pm 12:15-1:30pm
3/20 Village of 1:45-3:00pm
North Riverside 3:15-4:30pm
3/27 Bulger Park, Circle Lanes
Melrose Park
CLICK HERE PROGRAM KEY:
IN-PERSON PROGRAMS SOCIAL CLUB
TO REGISTER” FOR VIRTUAL VIRTUAL PROGRAMS 7:00-8:00pm
AND IN-PERSON PROGRAMS * IN-PERSON & VIRTUAL
Imaginarium - Sensory Room
WS S R A ’ s
WSSRA IS NOW OFFERING PRIVATE PLAY SESSIONS!
WSSRA is excited to offer private play session in our new Imaginarium Sensory Room. We have put
safety protocols in place to ensure the safety of participants, staff and family members. A list of
frequently asked questions, including safety protocols, will be sent upon registration.
CLICK HERE for the Imaginarium Frequently Asked Questions.
WINTER SPECIAL!
Participants will get private use of our sensory room for
45 minutes for the price of 30 minutes. Sign up for a time
slot that is most convenient for you! Punch cards can be Features of
carried over to another season and will expire after 1 year
of purchase.
WSSRA’s
Imaginarium
Age: All Ages, All Abilities & Siblings Sensory Room
Location: 228 Madison Street, Oak Park include:
Dates: 2/2 - 3/27 • Bubble tube
• Illuminated cabin
Hours: Tuesdays - Appointments between 3:30-6:45pm
Thursdays - Appointments between 1:00-6:45pm • Animated Sparkle Wall panel
Saturdays - Appointments between 9:30am-3:15pm • The Gesturetek Cube (an interactive floor
*must reserve your 45 - minute time slot in advance projection with over 75 special effects)
• Essential aromatherapy oils
Fee: $5 for a single visit • Calming music
$25 for a 5-visit punch card
$50 for a 12-visit punch card
• Sensory toys
*Punch cards can be shared with siblings; siblings must register Benefits Include:
separately. • Decreased anxiety
• 1 punch for an individual visit
• Fewer disruptive behaviors
• 2 punches for a family visit
• Promote mental and physical relaxation
For more information contact Christina Fernandez at (847) 455-2100. • Increase concentration
• Enhance learning through play
CLICK HERE to Schedule • Improve coordination & motor development
Your Private Play Session
8
Lekotek - Toy Lending Library
What is Lekotek? Who can participate?
WSSRA Lekotek Toy Lending Library is a resource Children ages birth-8 and family members are
center for families with children who have special welcome to participate. Play sessions are scheduled
needs. Our trained Lekotek leaders offer play session monthly based on the family’s availability.
for your entire family and will help you choose the Participants must be able to meet participation
toys you think your child will most enjoy for the eligibility guidelines.
following month. It operates very much like a
traditional library and having new toys in your home What does a play session look like?
each month will delight your children! All play sessions are conducted once a month for
one hour each session. Play sessions are led by our
Our Toys experienced Lekotek Leaders. Each session children
WSSRA’s Toy Lending Library houses over 2000 toys, are introduced to a variety of adapted toys making
games and play equipment. Some of our toys are play possible for ALL children. Participants can take
highly specialized to meet the needs of children who home up to eight toys monthly, new toys will be
are non-verbal and love toys that light up, play music exchanged each visit. Siblings, family members, and
and are easy to operate. caregivers are encouraged to participate.
Why Play? Where are play sessions held?
• Play helps build self-esteem and self-confidence Locations vary, play sessions are currently being held
• Play develops fine and gross motor skills at WSSRA Imaginaruim Sensory Room located at
• Play helps stimulate the mind and boosts creativity 228 Madison Street, Oak Park.
and problem-solving skills
• Play helps children use their imagination while Toy Delivery- NEW!
developing their cognitive and language skills WSSRA is now offering a contactless toy delivery
• Play helps improve social skills by demonstrating option which includes a virtual assessment and
positive social interactions among the child, parents tour of or our Lekotek Library. Toys will be delivered
and siblings monthly and our Lekotek Leaders will be available via
phone or Zoom to answer any questions about the
toys. All toys are properly sanitized before and after
each use with EPA approved disinfectants.
Schools and Therapists
Any special education teacher or therapist
serving children with special needs in our partner
communities are eligible to borrow toys from our
Lekotek Library.
Registration
Registration is ongoing throughout the year. Call the
WSSRA office for more information (847) 455-2100.
9
In-Person Program Guidelines/Protocols
WSSRA Participation Guidelines PARTICIPATION GUIDELINES
and Safety Protocols • Participant must have the ability to put on and wear a face
covering when necessary, for the duration of the program
WSSRA is excited to offer limited in-person program • Participant must be able to maintain a 6’ distance from other
opportunities based on state and federal regulations. participants and staff
All in-person programming is pending these • Participant must be able to follow directions with minimal
guidelines, WSSRA will open these guidelines further intervention by staff
as the regulations are updated. • Participant must be able to be successful with 4:1 staffing
and devoid of emotional outbursts requiring 1:1 staffing
WSSRA has put participation eligibility guidelines support
in place in order to comply with state and federal • Participant must be independent in managing personal care
regulations. A WSSRA staff member will conduct an including toileting, feeding, personal hygiene
assessment upon registration to determine eligibility.
WSSRA will allow participants who cannot meet these
guidelines to attend with an adult family member who SAFETY PROTOCOLS
lives within the same household to assist them to WSSRA has put the following safety protocols in
meet the guidelines. place in order to ensure the safety of participants,
staff and family members:
Please note: Participants traveling to one of the states • Participants and staff must complete a health screening
listed in the Chicago Emergency Travel Order are asked upon arrival
not to return to program for two weeks after returning • Participants and staff will wash hands upon arrival and
from the designate hotspot. For up-to-date details on throughout the program
the states listed in this order please visit • Participants must be dropped off to WSSRA staff at the
www.chicago.gov. facility entrance, parents and guardians will not be allowed
inside facilities
• Participants must be able to follow participation guidelines
per COVID-19 state mandates, safe behaviors will be strictly
enforced
• Programs will be limited to 8 participants per program with
2 staff
• All program spaces and equipment will be cleaned with an
EPA approved disinfectant between uses
• If WSSRA becomes aware that someone has been exposed to
COVID-19, we will take the appropriate steps as directed by
local health officials
• In the event of inclement weather WSSRA will do our best to
move programs indoors. If we cannot safely move a program
indoors, WSSRA will cancel or move the program to a virtual
option.
Questions?
If you have any questions or need assistance with
registration, please contact April Ryan at
aprilr@wssra.net or (847) 455-2100 ext. 231.
10In-Person Programs: Children & Youth
Explore the Arts (Age: 5 & older) Winter Wanderings (Age: 7-22)
Calling all artists!!! Join WSSRA to explore and express Calling all Explorers! Our Saturday mornings will consist of
ourselves through art. Each week we will create and fun excursions and going on new adventures. Please dress
explore a different art form. This program is offered both appropriately for both indoor & outdoor weather and bring
in-person and virtually. a water bottle.
Location: TBD Location: Carroll Center, Oak Park
Day Dates Time Fee Day/ Description Fee
Mon 2/1-3/22 6:00-7:00pm $46.80 Date/
Time
Sat Oak Park Conservatory - Today we $7.75
Dance Yoga (Age: 5 & older)
2/6 will be walking to the beautiful Oak
Enjoy the benefits of yoga and exercise through this fun
10:00- Park Conservatory to take a tour
class! This class combines fluid yoga movements to music
11:30am and learn all about their beautiful
to help increase strength, flexibility and coordination. All
plants.
skill levels are welcome, please bring a water bottle.
Sat Outdoor Fun - Join us as we head $7.75
Location: Andersen Center, Oak Park 2/20 outdoors for some fun and games!
Day Dates Time Fee 10:00- Activities may include sledding, arts
Wed 2/3-3/24 6:00-6:45pm $25.50 11:30am and crafts, sensory activities, and
active games.
Sat Horseback Riding - No experience $15.50
Rhythmic Gymnastics & Movement 3/6 necessary! Join us for a private
(Age: 8 & Older) 12:45- horseback riding session led by
Get your body moving in a fun new way! This program 2:00pm experienced staff. Participants
combines elements of gymnastics, dance, and fitness. must be able to sit independently
We will learn a fun routine using ribbon sticks and on a horse. Please meet us at the
exercises for overall body movement. We will also focus Hanson Center Riding Arena -
on improving flexibility and coordination skills. 15W431 E 59th St, Burr Ridge.
Location: Liberty Recreation Center, Berwyn Sibshops (Age: 7-13)
Day Dates Time Fee This program is designed for brothers and sisters of
Fri 2/5-3/26 5:00-6:00pm $34.00 children with special needs. Sibs will have the opportunity
to meet and talk with other sibs who “get it.” Participants
will also learn about the services their brothers and sisters
receive and most importantly play games and have fun!
Saturday Bowling League (Age: 8-21) Priority given to participants from Berwyn. Program
Strikes, spares, and splits, oh my! Join us as we
sponsored by Berwyn Township 708 Community Mental
sharpen our bowling skills and have fun with friends
Health Board.
while staying socially distanced. A maximum of 3
participants will be assigned to each lane using every Location: Proksa Park, Berwyn
other lane. Day Dates Time Fee
Sat 1/9 10:00am-12:00pm $1.00
Location: Circle Lanes, Forest Park Sat 1/23 10:00am-12:00pm $1.00
Day Dates Time Fee Sat 2/13 10:00am-12:00pm $1.00
Sat 2/6-3/27 12:15-1:30pm $53.50 Sat 2/27 10:00am-12:00pm $1.00
Sat 3/13 10:00am-12:00pm $1.00
Sat 3/27 10:00am-12:00pm $1.00
11In-Person Programs: Teens & Adults
Bobcats Skills and Drills (Age: 15 & older) Bingo (Age: 15 & older)
Join Bobcats in-person as we introduce various sports and Join your WSSRA friends as you try your luck at Bingo at our
fitness trainings each week. This program will initiate a variety new location. Prizes will be presented to weekly winners.
of different sports, fitness skills, and drills to assist in improving Please bring your own beverage.
our overall health. Please bring a water bottle. Let’s go Bobcats!! Location: Grant Park Recreation Center, Northlake
Location: Franklin Park Community Center Day Dates Time Fee
Day Dates Time Fee Thurs 2/11, 2/25, 3/11, 3/25 11:00am – 12:00pm $18.25
Tues 2/2-3/23 7:00-8:00pm $43.20
Socialites (Age: 18 & older)
Walk and Talk (Age: 15 & older) Gather with old friends and meet some new friends as you
Catch up with your WSSRA friends and staff as we get some participate in a variety of activities. Whether playing games,
exercise walking around The Village of Harwood Heights newly doing crafts, or watching movies, you are sure to have a great
built indoor track. Program will begin with a light warm up and time! Please bring a water bottle and dress for the weather.
end with a light cool down. Please bring your own water bottle. Location: Trumbull Park, River Grove
Locations: Village of Harwood Heights (VHH) Day Dates Time Fee
George A. Leoni Complex (GALC) Thurs 2/4, 2/18, 3/4, 3/18 6:30-8:00pm $27.30
Day Date Time Location Fee
Tues 2/2 10:15-11:15am VHH $4.55 TGIF (Age: 15 & older)
Tues 2/9 10:15-11:15am VHH $4.55 Who is ready for the weekend? Unwind, unplug, and join us for
Tues 2/16 10:15-11:15am VHH $4.55 some Friday evening fun! Catch up with friends while enjoying a
Tues 2/23 10:15-11:15am VHH $4.55 variety of games and activities. Please bring a water bottle.
Tues 3/2 10:15-11:15am GALC $4.55
Tues 3/9 10:15-11:15am GALC $4.55 Location: Park District of Forest Park, Building #4
Tues 3/16 10:15-11:15am GALC $4.55
Day/Date/ Description Fee
Tues 3/23 10:15-11:15am GALC $4.55
Time
Round Trip Transportation Fee: $6.50 per week
Fri Valentine’s Day Party - Will you be mine? $7.00
Transportation is limited and on a first come, first served basis.
2/12 Join friend’s as we celebrate love and
Participants must be able to get on and off the bus independently.
7:00- kindness by dancing, playing games,
8:30pm and making crafts.
Winner Takes All (Age: 18 & older)
Join us as we get together for some socializing, laughter, and Fri Hawaiian Luau – Escape the winter cold $7.00
games. We’ll play some old favorites and learn new games as 2/26 by joining us for a Hawaiian Luau. We
well. Please bring a water bottle. This program will be offered 7:00- will start the evening by making our own
both virtually and in person. 8:30pm floral lei and continue “Fun in the Sun”
Location: Elmwood Park Recreation Center with Hawaiian games and activities. Be
Day Dates Time Fee sure to dress in bright colors!
Wed 2/3-3/24 10:00 -11:00am $36.50 Fri St. Patrick’s Day Casino Night - Are you $7.00
Round Trip Transportation Fee: $6.50 per week 3/12 feeling a little Leprechaun lucky? We
Transportation is limited and on a first come, first served basis. 7:00- will play an assortment of Casino games
Participants must be able to get on and off the bus independently. 8:30pm and each participant will have the
opportunity to win a prize!
Powerlifting (Age: 16 & older)
Participants will learn the fundamentals and safety skills of Bowling League (Age: 22 & older)
performing three lifts: squat, deadlift and bench press. The Strikes, spares, and splits, oh my! Join us as we sharpen our
program will incorporate cardio and strength training and will bowling skills and have fun with friends while staying socially
allow for customized workout routines to meet individual needs. distanced. A maximum of 3 participants will be assigned to each
lane using every other lane.
Location: O’Hare CrossFit
Day Dates Time Fee Location: Circle Lanes, Forest Park
Wed 2/3-3/24 6:30-7:30pm $43.20 Day Dates Time Fee
Sat 2/6-3/27 1:45-3:00pm $53.50
Sat 2/6-3/27 3:15-4:30pm $53.50
12In-Person Programs: Special Events
Family Skate Night Age: All Ages, Siblings
Join us for a night of socially distanced ice-skating for the whole family- no experience is required!
Please wear any protective equipment that is necessary such as helmets or pads. Skates will be provided;
we will call you in advance to get your skate size to avoid waiting in line.
Please note: Preregistration is required, all participants must be accompanied by an adult.
Location: Ridgeland Commons Recreation Center, Ice Arena
Day Dates Time Fee
Fri 2/19 6:45-7:30pm $3*
Fri 2/19 7:30-8:15pm $3*
*per participant - parents and guardians are free.
Hippity Hoppity Hunt
Age: All Ages, Siblings
Hop on over to help us find all the eggs the bunny hid in the park!
This family friendly event will consist of a visit with the Bunny
an egg-travagant egg hunt, sensory egg coloring, and much more!!
This event will be held indoors and outdoors, please dress for the weather.
Please note: Preregistration is required, all participants must be accompanied by an adult.
Location: Village of North Riverside Location: Bulger Park Community Center,
Day Dates Time Fee* Melrose Park
Sat 3/20 10:00-11:00 $3* Day Dates Time Fee*
Sat 3/20 11:30-12:30 $3* Sat 3/27 10:00-11:00 $3*
*per participant Sat 3/27 11:30-12:30 $3*
*per participant - parents and guardians are free.
13Virtual Programming
What is virtual programming?
Reconnect with friends and try one of WSSRA’s virtual programs!
WSSRA’s Virtual Programs are designed for our participants to stay active and
connected during these times.
What type of technology is needed to
participate in virtual programs?
All programs are conducted through Zoom.
Thank you
Participants will need access to the internet and a
computer with a web camera. Programs can also be to our sponsors
accessed with a smart phone or tablet by downloading
the Zoom app. CLICK HERE for zoom instructions. for supporting
How to register for virtual programs
WSSRA’s virtual
In order to participate in virtual programs,
participants must complete a registration form.
programming
Regisration forms can be submitted: Berwyn Community
• Online at wssra.net
Development Block Grant
• Droped off at or mailed to the office at
WSSRA- 2915 Maple Street,
Franklin Park, IL 60131 Byline Bank
• Emailed to Noly at nolyh@wssra.net
Senator Phil Rock
• Faxed to (847) 455-2157
Scholarship Fund
What else should I know? Thumbuddy Special
• Imaginarium appointments must be made 24 hours in advance
• WSSRA’s virtual programs are designed for WSSRA participants West Suburban
and family members
Special Recreation
• For scholarship information, please contact Annie Hart at
annieh@wssra.net or (847) 455-2100 ext. 230 Foundation
Questions? Help Support WSSRA’s
If you have questions regarding virtual programs
or need assistance with registration, please call Virtual Programs
the WSSRA office at (847) 455-2100. CLICK HERE TO DONATE
14Virtual Programs: All Ages
Explore the Arts - Virtual (Age: 6 & older) Afterschool Adventures - Virtual
Calling all artists!!! Join WSSRA to explore and express This program is designed for students to learn and
ourselves through art. Each week we will create and experience new leisure activities virtually! We will
explore a different art form. This program is offered both participate in fun socialization games, virtual field trips,
in-person and virtually. Supply kits will be delivered to healthy living and more.
those who chose to join virtually. Supply kits will contain
all materials needs to participate in the program. Day: Thursdays
Day Dates Time Fee Time: 4:30-5:00pm
Mon 2/1-3/22 6:00-7:00pm $10.00 Fee: Free
Monday Night Sports Talk - Virtual 2/4 Trivial Pursuit! Grab a paper and pen to test your
Join us as we talk about the best moments in sports from
knowledge of fun facts! We will play friendly rounds
the week and a chance to socialize with your friends. Don’t
forget to wear your favorite jersey!
of trivia on topics such as animals, music, sports, and
Day Dates Time Fee movies!
Mon 2/1-3/22 6:30-7:00pm Free 2/11 Valentine's Social! Join us for an afterschool hangout!
We will play games and learn more about each other.
Weekly Workout - Virtual
This at-home workout will get you moving and your 2/18 Let's Wander! We are virtually transporting to Yosemite
heartbeat and energy up! Class will incorporate National Park. We will take a hike and enjoy the beautiful
stretching, cardio and strength and conditioning to trails with friends.
help build muscle and endurance. All you need is an 2/25 What is FUN, for 500? *Jeopardy Music Playing* Let's
open space and a positive mindset! play this classic game of Jeopardy as a group!
Day Dates Time Fee
Participants will take turns earning points by answering
Mon 2/1-3/22 7:15-7:45pm Free
fun questions.
Yoga - Virtual 3/4 Animals Crossing! Come with us to explore different
Participants will not only practice yoga, they will learn virtual ZOO's! We will look at live cams of animals and
mindfulness and practice guided meditations. Each week learn more about different species.
we will have new themes such as animal, superhero, and
more! 3/11 Move it, Move it! Get your body moving in our virtual
Day Dates Time Fee workout! We will focus on building our endurance and
Tues 2/2-3/23 4:30- 5:00pm Free strength skills in this fun workout class.
3/18 Calling All Rock Stars! Let's jam to our favorite songs!
Let’s Dance - Virtual Each participant will have the spotlight to sing along to
Dance your way to a healthier you! Participants will learn a your song pick.
variety of dance led by certified dance instructor, Sidney
McNeal. 3/25 Peace & Mind! We are going to follow a virtual yoga
Day Dates Time Fee instructor in learning beginner poses! This class will
Wed 2/3-3/24 6:15-7:00pm $10.00 focus on improving our flexibility and strength skills.
Participants will also practice mindfulness to relax any
Music Makers - Virtual after school worries.
This class incorporates singing, dancing, and making
music. It will be led by a certified music therapist from
Dynamic Lynks.
Day Dates Time Fee
Thurs 2/4-3/25 5:30-6:15pm $10.00
15Virtual Programs: All Ages
Virtual Adventures Dice Bowling - Virtual
We are taking adventure to the next level by virtually Come roll with us! Dice bowling can be played
transporting to extraordinary places around the world anywhere, anytime, all you need is a pair of dice
without leaving the comfort of your home. During this and some luck! Please bring 2 dice to program.
interactive program, we will visit famous vacation spots, Day Dates Time Fee
museums, art exhibits, landmarks, and more via Zoom. Sat 2/6-3/27 10:30-11:15am Free
Day Dates Time Fee
Fri 2/5-3/26 10:30-11:00am Free
Creative Cardio Workout - Virtual
Become a healthier you by joining WSSRA friends for this
unique workout that combines kickboxing and interval
training all to your favorite tunes! Please have a water
bottle to hydrate during class.
Day Dates Time Fee
Sat 2/6-3/27 9:45-10:15am Free
Virtual Programs: Special Events
Master Valentine’s Day
Chef Virtual Dance
Age: All Ages
Age: All Ages
We are going to STIR up some fun! Grab your dancing shoes and join
Join us in a virtual cooking class where participants
and families will make a delicious homemade pizza us for a Virtual Valentine’s Day
meal. Families will receive a cooking kit that will Dance! Come dressed to impress
consist of all the materials to make a homemade and have a great night with your
pizza and roasted zucchini. Supplies will make 4-5 WSSRA friends! Please send song
individual pizzas or 1 large pizza. A WSSRA staff will requests to SylviaD@wssra.net.
walk you through the recipe steps to become a
Master Chef.
Date: 2/13
Date: 1/22 Day: Saturday
Day: Friday Time: 7:00pm – 8:00pm
Time: 5:30-6:30pm Fee: Free
Fee: $10.00
16Virtual Programs: Teens & Adults
Mindful Mornings - Virtual Virtual Theatre (Age: 15 & Older)
Ease into your morning by joining us as we learn and Calling all actors! Join us as we work together to put
practice yoga and mindfulness techniques that will on a virtual production of Alice in Wonderland! We will
help us stay in tune throughout our day. pick rolls and work together on adapting the play to
Day Dates Time Fee fit a virtual platform, remembering lines and putting
Mon 2/1-3/22 10:30-11:00am Free together costumes with things around the house!
Day Dates Time Fee
Morning Mixer - Virtual Thurs 2/4-3/25 6:45-7:30pm Free
Grab your favorite morning drink and join friends to
chat and play games chosen by the group. Food Critics - Virtual
Day Dates Time Fee What’s on your plate? In this virtual version of Food
Tues 2/2-3/23 10:30-11:00am Free Critics, we will share what we’re having for dinner and
socialize with our peers.
Winner Takes All Day Dates Time Fee
Join us as we get together for some socializing, Fri 2/12, 2/19, 3/5, 6:00 – 6:30pm Free
laughter, and games. We’ll play some old favorites 3/12, 3/26
and learn new games as well. This program will be
offered both virtually and in person. Showtime - Virtual
Day Dates Time Fee Bring your own popcorn as we watch short films
Wed 2/3-3/24 10:00 -11:00am Free followed by a group discussion on what everyone
thought of them.
Home Design Time - Virtual Day Dates Time Fee
Tune in each week as we organize, decorate, and DIY Fri 2/5, 2/26, 3/19 6:00pm – 6:30pm Free
our way through our homes. Every week will consist
of organization tips & tricks for your space. We will
also be creating seasonal decoration pieces to hang
throughout our homes. Supply kits will be delivered
to participants and will contain all materials needs to
participate in the program.
Day Dates Time Fee
Wed 2/3-3/24 4:30-5:15pm $10.00
Healthy Start - Virtual
Grab your water bottle and join us for a fun workout
including cardio, strength and flexibility! Exercises
can be done from a chair or standing.
Day Dates Time Fee
Thurs 2/4-3/25 10:30-11:00am Free
17Virtual Programs: Teens & Adults
Social Club - Virtual
Join a club for some Saturday evening fun! We’ll have
weekly virtual activities with friends while focusing
on enhancement of social skills.
Day: Saturdays
Time: 7:00 – 8:00pm
Fee: Free
2/6 Showtunes with Charlie - Charlie Carpenter NEW! Bobcats
will join us this evening to sing and play our
favorite Showtunes on piano! ROAR Program
2/13 Virtual Valentine’s Day Dance (Reaching Out Across Recreation)
Join us for this Virtual Special Event! (Age: 18 & Older)
Turn to page 16 for more information.
2/20 Music Bingo - A fun twist on Bingo! Hear the
song and mark your card! Please register by
Do you love to have fun and
2/12. Cards will be emailed out for printing or want to help others enjoy their
mailed upon request.
recreation time as well?
2/27 Karaoke - Warm up your singing pipes! It’s
karaoke time with your WSSRA friends!
Join Bobcats ROAR and become a leader
3/6 Paint and Sip - Paint along with step by step in your community by helping others tap
instruction to create a beautiful Spring into fun. Members of this group will meet
painting while you sip on your favorite
non-alcoholic beverage. Please register by
monthly to create and implement
2/26. Supplies will be delivered to registered recreations projects that will bring
participants. fun to our surrounding communities.
3/13 Cherish the Memories - Tonight we will be
creating scrapbook pages and sharing found Virtual Informational Meeting:
memories. Please bring pictures and Saturday, January 30
supplies to use for scrapbooking.
3/20 Sign Language - Let’s learn some sign Time: 6:15-6:45pm
language and show off what we might
already know! Fee: Free
3/27 Mascot Night - Let’s get together to learn
about many Chicago sports team Mascots! For more information, please contact
Kelly Baran at kellyb@wssra.net or
847-455-2100 x239.
18Virtual Programs
Virtual Chat with a WSSRA
Staff Member
WSSRA staff want to know what you are up to!
Register for a 20-minute Zoom hangout session
with a with WSSRA staff member.
ENJOY
• Games
CLICK HERE
• Great conversation TO SCHEDULE
• And more! YOUR SESSION
19Special Olympics Guidelines
Illinois Special Olympics provides year round sports training in a variety of Olympic-type sports for individuals
who are 8 years and older and who have mental impairments or closely related developmental disabilities.
The program gives athletes opportunities to develop physical fitness, demonstrate courage, experience joy and
participate in the sharing of skills and friendship with their families and other athletes. WSSRA supports
the mission of Special Olympics through the participation in the following sports:
Aquatics, Basketball, Bowling, Softball, Track & Field, Volleyball, Bocce, Powerlifting & Snowshoeing.
Please note that the safety of the athletes, coaches, and families is our top priority. All sports and competitions will be assessed
individually and will follow the guidelines set by the CDC and Illinois Department of Public Health. WSSRA will continue offering
Bobcats Skills and Drills which will focus on sports specific conditioning and skill-based exercises for future competition.
Criteria for Participation
All Special Olympic athletes must have a current, completed Application for Participation in Illinois Special
Olympics on file with the Special Olympic coordinator at WSSRA. This form contains 4 sections:
1. Athlete information
2. Parent and/or Guardian Authorization & Medical Authorization
3. Health Insurance and Emergency Information
4. Medical Clearance (this MUST be completed by a physician)
Applications for Participation in Illinois Special Olympics are valid for 3 years based on the earliest signed date on
the medical application form. See page 21 for the Application.
Anyone interested in participating or volunteering, please contact the WSSRA Special Olympic Coordinator.
Expectations
We all share a responsibility in making the Special Olympics training and competition program a positive
experience that promotes the growth & development of our athletes. It is in this belief that we have
identified the below expectations for our WSSRA Athletes, Parents, & Spectators:
WSSRA’s Expectations of Athletes
1. Demonstrate respect for the rules of the sport.
2. Demonstrate respect for coaches, teammates, opponents, opposing coaches and officials.
Failure to do so may result in loss of playing time.
3. Come to practices and games ready to play with a positive attitude.
WSSRA’s Expectations of Parents & Spectators
WSSRA spectators are asked to provide positive support during practice and competition.
Negative comments are incredibly detrimental to team morale.
Spectators are expected to:
1. Show respect & positive support for ALL WSSRA athletes and our opponents.
2. Show respect & positive support for ALL WSSRA coaches, opposing coaches, officials,
and other spectators
3. Be a role model for proper behavior and demonstrate good sportsmanship, and self-discipline.
20APPLICATION FOR PARTICIPATION IN SPECIAL OLYMPICS ILLINOIS
Valid Application for Participation is mandatory for all competitors
Region
605 E. Willow St. · Normal, IL 61761-2682 · 309-888-2551 SOILL Rev. 6-15-20
MEDICAL CLEARANCE
ATHLETE INFORMATION Birthdate
Athlete Name (last name, space, first name) M M D D Y Y PLEASE CHECK MEDICAL INFORMATION
Does athlete have Down Syndrome?
Yes □ No □
Agency Name Sex (M or F)
If yes, have x-rays of the C1-C2 vertebrae
been taken and examined?
Athlete’s Mailing Address Parent’s/Guardian’s (Please Circle One) Home Address
Yes □ No □
Date of x-ray ____________________
Is the athlete clear of Atlantoaxial Instability?
Athlete’s City Parent’s/Guardian’s City Yes □ No □
Does the athlete have or is the athlete:
Heart Problems Yes □ No □
State Zip Code State Zip Code
Diabetic Yes □ No □
- - Epileptic/Seizures Yes □ No □
Blind Yes □ No □
□ White □ Black/African American □ Asian Parent’s/Guardian’s Deaf Yes □ No □
Ethnicity □ Hispanic/Latino □ Other ________________________________________ Home Telephone - -
Hepatitis Yes □ No □
Other ______________________________
HEALTH INSURANCE & EMERGENCY INFORMATION (Required for Processing)
Person to be contacted Emergency Current Medication Dosage
in case of emergency ______________________________________________ Contact Phone (_______)________________________________________ _____________________________________
_____________________________________
Medical Insurance Company ________________________________________ Policy Number ________________________________________________
_____________________________________
PARENT AND/OR GUARDIAN AUTHORIZATION AND MEDIA RELEASE
I, on my own behalf or as the undersigned parent and/or legal guardian of the above named applicant (hereafter referred to as the “Entrant”), hereby request permission for the Entrant to
participate in Special Olympics programs. I acknowledge that Special Olympics will screen all entrants using the Sex Offender Public Registry and the Child Murder and Violent Offender Allergies to medication, if any: ____________
Against Youth Registry and understand that entrants listed on either Registry will be denied participation. I affirm that this Entrant has never been on said Registries or, if Entrant was listed
on either Registry but has since been removed, I will contact Special Olympics Illinois for instructions before submitting this application. _____________________________________
I represent and warrant to you that the Entrant is physically and mentally able to participate in Special Olympics, and I submit herewith a subscribed medical certificate. I understand that if
Date of last Tetanus shot: ________________
the athlete has Down syndrome, he/she cannot participate in sports or events which, by their nature result in hyper-extension, radical flexion or direct pressure on the neck or upper spine
unless a full radiological examination established the absence of Atlantoaxial Instability. I am aware that the sports and events for which this radiological examination is required are
equestrian sports, artistic gymnastics, diving, pentathlon, high jump, alpine skiing, soccer, soccer skills, powerlifting squat, and butterfly stroke and diving starts in swimming. I have examined the above-named
On behalf of the Entrant and myself, I acknowledge that the Entrant will be using facilities at his/her own risk and I, on my own behalf, hereby release, discharge and indemnify Special
Entrant and, in my opinion, there is no
Olympics from all liability for injury to person or damage to property of myself and Entrant. mental or physical reason why he or
In permitting the Entrant to participate, I am specifically granting permission to Special Olympics Illinois to use the likeness, voice and words of the Entrant in television, radio, films, she should not participate in the
newspapers, magazines and other media, and in any form not heretofore described, for the purpose of advertising or communicating the purposes and activities of Special Olympics and in Special Olympics sports training and
appealing for funds to support such activities. I understand that by signing below I consent for the Entrant to participate in the Special Olympics Healthy Athletes Program that provides competition program. Further informa-
individual screening assessments of health status and health care needs. The Entrant has no obligation to participate and I understand the Entrant should seek his/her own medical advice tion will be forwarded if required.
and assistance and Special Olympics is not responsible for the Entrant’s health. Current medication, if any, is specified
If I am not personally present at Special Olympics activities in which the Entrant is to compete, so as to be consulted in case of necessity, you are authorized on my behalf and at my with dosage on this application.
account to take such measures and arrange for such medical and hospital treatment as you may deem advisable for the health and well-being of the Entrant.
I, THE UNDERSIGNED ADULT ENTRANT, have read and fully understand the provi- I, THE UNDERSIGNED PARENT AND/OR GUARDIAN of the above specified Entrant, Examination Date ______________________
sions of the above release and/or have had them explained. I hereby agree that I will be have read and fully understand the provisions of the above release and have explained them
bound thereby and I shall defend Special Olympics Illinois and hold it harmless from disaf- to said Entrant. I hereby agree that I and said minor will be bound thereby, and I shall defend Doctor’s Signature ______________________
firmation thereof. Special Olympics Illinois and hold it harmless from any disaffirmation thereof by said minor.
Print Name ___________________________
Entrant _________________________________________________________________ Signature of Parent □
and/or Legal Guardian □ ___________________________________________________ Address ______________________________
□ Athlete is own guardian (Check appropriate box)
Witness ___________________________________________ Date ________________ Print Name _________________________________________ Date ________________ City _______________ State ____ Zip ______
Athlete’s Email Address ____________________________________________________ Parent’s Email Address _____________________________________________________ Phone (_____)_________________________
S1-9
APPLICATION FOR PARTICIPATION IS VALID FOR 3 YEARS FROM EXAM DATESOLICITUD DE PARTICIPACIÓN EN OLIMPÍADAS ESPECIALES DE ILLINOIS
Válido Solicitud de Participación es obligatoria para todos los competidores
605 E. Willow St. · Normal, IL 61761-2682 · 309-888-2551 SOILL Rev 6-15-20 Region
INFORMACIÓN DEL ATLETA Fecha de nacimiento APROBACIÓN MÉDICA
M M D D Y Y (MEDICAL CLEARANCE)
Nombre del atleta (apellido espacio nombre)
FAVOR DE CHEQUEAR LA INFORMACIÓN
MÉDICA (PLEASE CHECK MEDICAL IN FORMATION)
Nombre de la agencia Sexo (M or F)
Síndrome de Down (Down syndrome) Sí □ No □
Si el atleta tiene el síndrome de Down,
¿se ha tomado y hecho radiografías, o
Domicilio Postal del Atleta Domicilio de la casa de los padres o guardián (Por Favor Círculo Uno) rayos X de las vértebras C1-C2? Sí □ No □
(If athlete has Down syndrome, have x-rays of the C1-C2
vertebrae been taken and examined?)
Fecha de los rayos X (Date of x-ray) _________
Ciudad del atleta Ciudad de los padres o guardián ¿Tiene el atleta la aprobación de la
Inestabilidad Atlanto-Axial? Sí □ No □
(Is the athlete clear of Atlantoaxial Instability?)
Estado Código postal Estado Código postal ¿Es o tiene el atleta?: (Does the athlete have or is the
athlete:)
- - Sí □ No □
Diabético (Diabetic) Sí □ No □
Epilépsia/Ataques epilepticos Sí □ No □
□ Blanco □ Negro/Afroamericano □ Asiático Teléfono de casa de (Epileptic/Seizures)
Etnicidad □ Hispano/Latino □ Otro ________________________________________ los padres o guardián - - Invidente (Blind) Sí □ No □
Sordo (Deaf) Sí □ No □
INFORMACIÓN SOBRE EL SEGURO DE SALUD Y EMERGENCIAS (Requerido para Procesamiento) Hepatitis (Hepatitis) Sí □ No □
Otros (Other) _________________________
En caso de Teléfono de
emergencia avisar a _______________________________________________ Emergencia (_______)________________________________________
Medicina que toma actuamente Dosis
(Current Medication) (Dosage)
Compañía de seguro médico ________________________________________ Número de póliza _____________________________________________
_____________________________________
AUTORIZACIÓN PATERNAL O DEL GUARDIÁN Y EL PERMISO PARA LA PRENSA
_____________________________________
_____________________________________
Alergias a medicinas (si tiene alguna): (Allergies
to medication, if any:)
_____________________________________
Fecha de la última inyección para el Tetano:
(Date of last Tetanus shot:) _____________________
I have examined the above-named Entrant
and, in my opinion, there is no mental or
physical reason why he or she should not
participate in the Special Olympics sports
training and competition program. Further
information will be forwarded if required.
Current medication, if any, is specified with
dosage on this application.
Examination Date ______________________
Doctor’s Signature ______________________
Print Name ___________________________
Firma del padre □
Entrante ________________________________________________________________ o guardian □ _______________________________________________________________ Address ______________________________
(Marque las cassilla apropiada)
□ Atleta es su propio guardián
Nombre (letra de molde) ________________________________ Fecha _______________ City _______________ State ____ Zip ______
Testigo ___________________________________________ Fecha ________________
La dirección electrónica de los padres ___________________________________________ Phone (_____)_________________________
La dirección electrónica del participante _ ______________________________________
S1-11
SOLICITUD DE PARTICIPACIÓN ES VÁLIDA POR 3 AÑOS DESDE LA FECHA DE EXAMENYou can also read
