Adaptive Equipment Lending Adaptive Sports Equipment Request Use this form to request use of a variety of adaptive sports equipment for use independent of our programs. "*" indicates required fields ATHLETE Name (First, Last)* First Last Enter first name in first box and last name in second box. Please enter the ATHLETE's name here if parent/guardian is checking out equipment.Name of Person Responsible for Item (if athlete listed above is a minor*) (First, Last) First Last Enter first name in first box and last name in second box. Please enter the ADULT (parent/guardian) name here if applicable.Email* Enter your e-mail address.Phone*Please enter your phone number, including your area code.Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Organization/Group Name (if applicable) Please list your organization or group name if borrowing a piece of equipment for use on behalf of a group.What Piece of Adaptive Sports Equipment Are You Requesting?*Sports WheelchairBoccia Ball SetHand CycleRacing Chair / Track ChairOtherPlease select the piece of adaptive equipment you are requesting from the dropdown menu.Item Specifics (If Known) If brand/model/size/Inventory # is known, please list all information here. This question does not apply to general requests. Date Needed* By what date is the item needed? Estimated RETURN Date* By what date will you return the borrowed item? (Please e-mail information@synergyaa.com for adjusted requests.)Replacement of Damaged Equipment* I agree to pay for damages associated with my use of this equipment.I agree to use this equipment in the proper manner as intended. Synergy/WDSRA does not charge back for occurrences such as popped tubes, 1-2 broken spokes, and other minor repairs associated with typical wear and tear when equipment is used appropriately. If equipment is significantly damaged as a result of my use I agree to repair damage or replace equipment with equivalent piece of equipment.Helmet Usage for Hand Cycles and/or Racing Chairs* I agree to wear a helmet at all times while using a hand cycle or racing chair.Helmets are required safety equipment when using a WDSRA/Synergy hand cycle and/or racing chair. It is also recommended that you use a flag on the back of hand cycles as you are lower than line of sight for other vehicles. Liability Waiver* I agree to all conditions set forth within this liability waiver.Waiver & Release Western DuPage Special Recreation Association Important Information Synergy Adaptive Athletics is a program of the Western DuPage Special Recreation Association (WDSRA). WDSRA is committed to conducting its recreation programs and activities in a safe manner and holds the safety of participants in high regard. WDSRA continually strives to reduce such risks, and insists that all participants follow safety rules and instructions that are designed to protect the participants' safety. However, participants and parents/guardians of minors registering for this program/activity must recognize that there is an inherent risk of injury when choosing to participate in recreational activities. You are solely responsible for determining if you or your minor child/ward are physically fit and/or skilled for the activities contemplated by this agreement. It is always advisable, especially if the participant is pregnant, disabled in any way or recently suffered an illness, injury or impairment, to consult a physician before undertaking any physical activity. Warning of Risk Recreational activities are intended to challenge and engage the physical, mental and emotional resources of each participant. Despite careful and proper preparation, instruction, medical advice, conditioning and equipment, there is still a risk of serious injury when participating in any recreational activity/program. Understandably, not all hazards and dangers can be foreseen. Participants must understand that certain risks, dangers and injuries due to acts of God, inclement weather, slipping, falling, equipment failure, failure in supervision, premises defects and all other circumstances inherent to recreational activities/programs exist. In this regard, it must be recognized that it is impossible for WDSRA to guarantee absolute safety. Waiver and Release of All Claims and Assumption of Risk Please read this form carefully and be aware that in signing up and participating in this program/activity, you will be expressly assuming the risk and legal liability and waiving and releasing all claims for injuries, damages or loss which you or your minor child/ ward might sustain as a result of participating in any and all activities connected with and associated with this program/activity (including transportation services, when provided). I recognize and acknowledge that there are certain risks of physical injury to participants in this program/activity, and I voluntarily agree to assume the full risk of any and all injuries, damages or loss, regardless of severity, that my minor child/ward or I may sustain as a result of said participation. I further agree to waive and relinquish all claims I or my minor child/ward may hove (or accrue to me or my child/ward) as a result of participating in this program/activity against WDSRA, including its officials, agents, volunteers and employees (hereinafter collectively referred as WDSRA). I do hereby fully release and forever discharge WDSRA from any and all claims for injuries, damages, or loss that my minor child/ ward or I may have or which may accrue to me or my minor child/ward and arising out of, connected with, or in any way associated with this program/activity. Photo/ Video Release I hereby authorize and give my consent to WDSRA to photograph/video my child (or me) or to obtain outside photographs/video of my child (or me) participating in WDSRA activities/events/programs, and without limitation, to use such photographs/video in connection with promoting/advertising the services, programs, and facilities of WDSRA, without consideration of any kind. Your electronic signature shall substitute for and have the same legal effect as an original form signature. Medical Care Release I give permission to WDSRA staff and/or representatives from competing organizing committees and/or outside sport team representatives to seek medical care on my behalf in the event of an emergency and agree that I will be responsible for payment of any and all medical services rendered. Δ
