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| <HTML> | |
| <HEAD> | |
| <META HTTP-EQUIV="Content-Type" CONTENT="text/html; charset=windows-1252"> | |
| <META NAME="Generator" CONTENT="Microsoft Word 97"> | |
| <TITLE>IT IS THE MANDATE OF THE ONTARIO GYMNASTIC FEDERATION TO PROVIDE SAFE GYMNASTICS TO ALL WHO PARTICIPATE</TITLE> | |
| </HEAD> | |
| <BODY> | |
| <U><FONT FACE="Grinder"><P> </P> | |
| <P>Draft #4 </P> | |
| </U></FONT><FONT SIZE=4><P>The Ontario Gymnastic Federation’s Special Needs Policy</P> | |
| </FONT><FONT FACE="Arial"><P>I) <U>Introduction:</P> | |
| </U></FONT><FONT FACE="Arial" SIZE=2><P>According to the Ontario Human Rights Code: </P> | |
| <B><P>a)</B> Individuals with disabilities cannot be denied services based on their special needs.</P> | |
| <P>"It is a discriminatory practice in the provision of goods, services, facilities or accommodation customarily available to the general public (a) to deny, or to deny access to, any such good, service, facility or accommodation to any individual, or (b) to differentiate adversely in relation to any individual, ...on a prohibited ground of discrimination."</P> | |
| <B><P>b)</B> The Ontario Gymnastic Federation has developed policies and guidelines for its member Clubs in order to maximize the safety of all its members. Clubs do have the right and responsibility to decide the types of safe and affordable programs that can be suitably provided to accommodate individuals with special needs.</P> | |
| </FONT><FONT FACE="Arial"><P>II) <U>DEFINITION OF SPECIAL NEEDS:</U> </P> | |
| </FONT><FONT FACE="Arial" SIZE=2><P>Individuals who are mentally or physically challenged, or who have medical condition(s) that might require modifications to a gymnastic program to suit their needs, (e.g.: visual impairment, cerebral palsy, polio, downs syndrome, hearing impairment, autism, spina bifida, etc…) <U>or<B>,</B></U> who have any medical, mental or physical condition(s) that, for safety reasons, the <U>Host Club and coach</U> should be made aware of. (e.g.: hydrocephalus requiring a shunt, downs syndrome, predisposition to seizures, prosthesis, etc…).</P> | |
| </FONT><FONT FACE="Arial"><P>III) <U>NOTIYING THE OGF:</P><DIR> | |
| </U></FONT><FONT FACE="Arial" SIZE=2><P>1) 	Any OGF Club having individuals with Special Needs participating in their programs and who will be integrating/mainstreaming the individual, or providing custom designed programs for the individual, must notify The OGF, via application, of their intent to offer any programs, prior to the start of the program. Before programming may begin, Clubs must adhere to all OGF Special Needs policies. Failure to comply may negate the Host Club’s insurance coverage and/or their good standing within the Federation.</P></DIR> | |
| <OL START=2> | |
| <LI>The parent or caregiver of all OGF participants including those with Special Needs or conditions, must complete and submit one copy to the host club, the <U>Participant Consent and Medical Information Form</U> (Form A) prior to the individual participating in any regular (integrated) or special program. </LI></OL> | |
| </FONT><FONT FACE="Arial"><P>IV) <U>PERSONNEL:</P> | |
| <OL> | |
| </U></FONT><FONT FACE="Arial" SIZE=2><LI>Where a Participant Consent and Medical Information Form discloses the presence of a medical condition that may affect the individual’s participation in any program activities, the Club will then assess the individual.</LI></OL> | |
| <P>The Technical Advisor(s), and Head Coach from each Club, will assess an individual who has been identified as a special needs candidate and will assigned them to one of the following program groups:</P> | |
| </FONT><U><FONT FACE="Arial"><P>Group 1:</U></FONT><FONT FACE="Arial" SIZE=2> 	</P> | |
| <P ALIGN="JUSTIFY">fully integrated/mainstreamed<B> </P> | |
| </B></FONT><U><FONT FACE="Arial"><P>Group 2:</U></FONT><FONT FACE="Arial" SIZE=2> 	</P> | |
| <P>integrated/mainstreamed with an assistant</P> | |
| <P>assistant can be provided by participant’s parent/caregiver who must be registered with The OGF. <U>Or<B> </B></U>assistant can be provided by the Host Club (at the Host Clubs expense) and who must be registered with The O.G.F.</P> | |
| </FONT><U><FONT FACE="Arial"><P>Group 3:</U></FONT><FONT FACE="Arial" SIZE=2> </P> | |
| <P>recommended to a modified program that best suits his/her ability level/needs<B> </P> | |
| </B><P>program to be delivered by the Club using professional assistants with expertise in the areas of need of each individual. Assistants can be provided by either the participant or the club and at the club’s discretion expenses for the assistant to be covered by either the participant or the club, if the program is scheduled for an organized group(s), a certificate naming The OGF as additional insured including a Cross Liability Clause, is required</P> | |
| </FONT><U><FONT FACE="Arial"><P>Group 4:</U></FONT><FONT FACE="Arial" SIZE=2> 	</P> | |
| <P>Individual not recommended for some or all gymnastic disciplines based on medical and safety reasons</P> | |
| <P>2) The Club must keep on file, all Participant Consent and Medical Information Forms (Form A) and, where required all completed Technical Advisors’ recommendations. This form <U>MUST</U> be completed for all competitive and interclub athletes and each club will be responsible for forwarding 1 copy of Form A to The O.G.F. upon registration of the individual. For recreation level participants only, clubs may elect to use The O.G.F. Participant Consent and Medical Information Form (Form A) in its current format or the club may elect to incorporate the contents of the Participant Consent and Medical Information Form (Form A) into their own individual club registration forms. It is imperative that <U>ALL</U> information requested in Form A be collected and filed by the club. The OGF may, at any time, request this information from the Club. In the event of an accident, the Participant Consent and Medical Information Form (Form A) or the clubs Incident Report Form<B> </B>to The OGF. individual recreation consent and medical form must accompany the Accident </P> | |
| <P> </P> | |
| <P>3) The Club must have the following PERSONNEL in place prior to a individual with Special Needs participating in a program (one person may hold more than one position):</P> | |
| <U><P>SPECIAL NEEDS CLUB CONTACT</P> | |
| </U><P> </P> | |
| <P>Person to liase with The OGF and represent club members with Special Needs</P> | |
| <P>Reports directly to the Club’s Board of Directors</P> | |
| <P>Responsible for ensuring compliance by the club of all OGF Special Needs policies </P> | |
| <P>Ensures all required paperwork is completed and submitted to The OGF prior to the commencement of any special needs programs.</P> | |
| <P>Ensures that all professional assistants representing outside organizations provide a certificate naming The OGF as additional insured</P> | |
| <P>Ensures that all assistants<B> </B>provided by the participant or by the host club,<B> </B>and who are accompanying the individual, are registered with OGF</P> | |
| <U><P>SPECIAL NEEDS TECHNICAL ADVISOR(s)</U> </P> | |
| <P>The Special Needs Technical Advisor shall be a: Physician, Physical Therapist, Occupational Therapist or any person qualified to conduct Functional Assessments </P> | |
| <P>The Special Needs Technical Advisor will <B>r</B>eview individuals’ applications who have any conditions as outlined in Form B of the Participant Consent and Medical Information Form.</P> | |
| <P>In consultation with the Special Needs Head Coach, the Special Needs Technical Advisor<B> </B>will assess the individual with Special Needs and designate the individual to one of the following groups:</P> | |
| <I><U><P>Group 1</U> – fully integrated/mainstreamed</P> | |
| <U><P>Group 2</U> - integrated/ mainstreamed with an assistant</P> | |
| <U><P>Group 3 </U>- recommended to a modified program that best suits individual’s ability level/needs <U>Group 4</U> - not recommended for some or all gymnastic disciplines based on medical/safety reasons</I>	</P> | |
| <P>The Special Needs Technical Advisor will advise the Head Coach of any limitations or safety measures that should be considered during the development of the program for each participant</P> | |
| <P> <U>HEAD COACH</P> | |
| </U><P> </P> | |
| <P>In consultation with the Special Needs Technical Advisor, the Head Coach will assess the individual with Special Needs and designate the individual to one of the following groups:</P> | |
| <I><P>Group 1 – fully integrated/mainstreamed</P> | |
| <U><P>Group 2</U> - integrated/ mainstreamed with an assistant		</P> | |
| <U><P>Group 3<B> </B></U>- recommended to a modified program that best suits his/her ability level/needs </P> | |
| </FONT><U><FONT SIZE=2><P>Group 4<B> </B></U> - not recommended for some or all gymnastic disciplines based medical/safety reasons</I>	</P> | |
| <P>In consultation with the Technical Advisor, will, where required, develop modified programs </P> | |
| </FONT><FONT FACE="Arial" SIZE=2><P>Identifies any specialized equipment and/or facility requirements that are needed to facilitate usage of the program/instruction by applicants with special needs.</P> | |
| <P>Selects coaches and provides any special ‘gymnastic’ information/data needed for coaches to properly instruct individuals with special needs</P> | |
| <P>Regularly monitors each coach’s instruction and overall program </P> | |
| <P> </P> | |
| </FONT><B><FONT FACE="Arial"><P> </P> | |
| <P> </P> | |
| </B><P>V) <U>COACHING CRITERIA:</U> </P> | |
| <B><P> </P> | |
| <P> </B></FONT><FONT FACE="Arial" SIZE=2>All coaches participating in a Special Needs program MUST be NCCP Level 1 certified for each discipline that he/she will be coaching. Prior to an individual participating in the class, the coach MUST<B> </B>review the Special Conditions Information Form, (Form B), the Abilities and Limitations Form, (Form C), and any recommendations made by the Technical Advisor (where required) and head coach for that individual. Any modifications to equipment or activities must be in place prior to the individual participating in an activity. The head coach must have successfully completed the<B> </B>NCCP Level 2 component from each discipline on which the special needs program/instruction is based. </P> | |
| <P>IT IS RECOMMENDED THAT ALL SPECIAL NEEDS COACHES RECEIVE CURRENT INFORMATION ON A REGULAR BASIS FROM THE SPECIAL NEEDS HEAD COACH AND/OR THE CLUB’S TECHNICAL ADVISOR(S). </P> | |
| </FONT><FONT FACE="Arial"><P>VI) <U>INSURANCE:</U>	</P> | |
| </FONT><FONT FACE="Arial" SIZE=2><P>All special needs participants are to be registered as recreational gymnasts with The O.G.F..</P> | |
| <P>Any assistant provided by and accompanying the participant must be registered with the O.G.F. as a supporter</P> | |
| <P>Any professional assistant representing an educational or medical </P> | |
| <P>institution or agency or community organization must have their employer provide a certificate naming The O. G.F. as additional insured and include a Cross Liability Clause prior to participating as an assistant in any program</P> | |
| <P>If the Club hires an assistant(s) to aid a participant(s), the Club is responsible to register the assistant as a ‘CIT’, or coach of recreation,<B> </B>depending on their qualifications<B> </B>and must adhere to all policies regarding "CIT’s" and coach of recreation </P> | |
| <P> </P> | |
| <P> </P> | |
| <P> </P> | |
| <P ALIGN="CENTER"> </P> | |
| </FONT><B><U><FONT FACE="Arial" SIZE=4><P ALIGN="CENTER"> FORM B</FONT><I><FONT FACE="Arial"> - SPECIAL CONDITIONS INFORMATION FORM</FONT><FONT FACE="Arial" SIZE=3> </P> | |
| </U></FONT><FONT FACE="Arial" SIZE=2><P ALIGN="CENTER">NAME OF PARTICIPANT_______________________________</P> | |
| </FONT><FONT FACE="Arial" SIZE=1><P ALIGN="CENTER"> 						please check</P></B></I></FONT> | |
| <TABLE BORDER CELLSPACING=1 CELLPADDING=7 WIDTH=590> | |
| <TR><TD WIDTH="4%" VALIGN="TOP" BGCOLOR="#ffffff"> </TD> | |
| <TD WIDTH="81%" VALIGN="TOP" BGCOLOR="#ffffff"> | |
| <B><I><FONT FACE="Arial"><P ALIGN="CENTER">CONDITION</P> | |
| </B></FONT><FONT FACE="Arial" SIZE=1><P ALIGN="CENTER">This section is to be completed by a <B>parent, guardian, caregiver, councilor, physician, physical therapist, occupational therapist or educator/teacher</B> who is familiar with the ability level and limitations of the participant:</I></FONT></TD> | |
| <TD WIDTH="7%" VALIGN="TOP" BGCOLOR="#ffffff"> | |
| <B><I><FONT FACE="Arial" SIZE=2><P ALIGN="CENTER">NO</B></I></FONT></TD> | |
| <TD WIDTH="7%" VALIGN="TOP" BGCOLOR="#ffffff"> | |
| <B><I><FONT FACE="Arial" SIZE=2><P ALIGN="CENTER">YES</B></I></FONT></TD> | |
| </TR> | |
| <TR><TD WIDTH="4%" VALIGN="TOP"> | |
| <FONT FACE="Arial" SIZE=2><P ALIGN="CENTER">1</FONT></TD> | |
| <TD WIDTH="81%" VALIGN="TOP"> | |
| <FONT FACE="Arial" SIZE=2><P>VISUAL OR HEARING IMPAIRMENT</FONT></TD> | |
| <TD WIDTH="7%" VALIGN="TOP"> </TD> | |
| <TD WIDTH="7%" VALIGN="TOP"> </TD> | |
| </TR> | |
| <TR><TD WIDTH="4%" VALIGN="TOP"> | |
| <FONT FACE="Arial" SIZE=2><P ALIGN="CENTER">2</FONT></TD> | |
| <TD WIDTH="81%" VALIGN="TOP"> | |
| <FONT FACE="Arial" SIZE=2><P>DIFFICULTY IN COMPREHENDING INSTRUCTIONS</FONT></TD> | |
| <TD WIDTH="7%" VALIGN="TOP"> </TD> | |
| <TD WIDTH="7%" VALIGN="TOP"> </TD> | |
| </TR> | |
| <TR><TD WIDTH="4%" VALIGN="TOP"> | |
| <FONT FACE="Arial" SIZE=2><P ALIGN="CENTER">3</FONT></TD> | |
| <TD WIDTH="81%" VALIGN="TOP"> | |
| <FONT FACE="Arial" SIZE=2><P>SEVERE ALLERGIES (EPINEPHRINE REQUIRED)</FONT></TD> | |
| <TD WIDTH="7%" VALIGN="TOP"> </TD> | |
| <TD WIDTH="7%" VALIGN="TOP"> </TD> | |
| </TR> | |
| <TR><TD WIDTH="4%" VALIGN="TOP"> | |
| <FONT FACE="Arial" SIZE=2><P ALIGN="CENTER">4</FONT></TD> | |
| <TD WIDTH="81%" VALIGN="TOP"> | |
| <FONT FACE="Arial" SIZE=2><P>DEVELOPMENTALLY DELAYED</FONT></TD> | |
| <TD WIDTH="7%" VALIGN="TOP"> </TD> | |
| <TD WIDTH="7%" VALIGN="TOP"> </TD> | |
| </TR> | |
| <TR><TD WIDTH="4%" VALIGN="TOP"> | |
| <FONT FACE="Arial" SIZE=2><P ALIGN="CENTER">5</FONT></TD> | |
| <TD WIDTH="81%" VALIGN="TOP"> | |
| <FONT FACE="Arial" SIZE=2><P>ATTENTION DEFICIT DISORDER</FONT></TD> | |
| <TD WIDTH="7%" VALIGN="TOP"> </TD> | |
| <TD WIDTH="7%" VALIGN="TOP"> </TD> | |
| </TR> | |
| <TR><TD WIDTH="4%" VALIGN="TOP"> | |
| <FONT FACE="Arial" SIZE=2><P ALIGN="CENTER">6</FONT></TD> | |
| <TD WIDTH="81%" VALIGN="TOP"> | |
| <FONT FACE="Arial" SIZE=2><P>ASTHMATIC (prone to attacks)</FONT></TD> | |
| <TD WIDTH="7%" VALIGN="TOP"> </TD> | |
| <TD WIDTH="7%" VALIGN="TOP"> </TD> | |
| </TR> | |
| <TR><TD WIDTH="4%" VALIGN="TOP"> | |
| <FONT FACE="Arial" SIZE=2><P ALIGN="CENTER">7</FONT></TD> | |
| <TD WIDTH="81%" VALIGN="TOP"> | |
| <FONT FACE="Arial" SIZE=2><P>PROSTHESIS</FONT></TD> | |
| <TD WIDTH="7%" VALIGN="TOP"> </TD> | |
| <TD WIDTH="7%" VALIGN="TOP"> </TD> | |
| </TR> | |
| <TR><TD WIDTH="4%" VALIGN="TOP"> | |
| <FONT FACE="Arial" SIZE=2><P ALIGN="CENTER">8</FONT></TD> | |
| <TD WIDTH="81%" VALIGN="TOP"> | |
| <FONT FACE="Arial" SIZE=2><P>LIMITED RANGE OF MOTION DUE TO INJURY, SURGERY, OR OTHER</FONT></TD> | |
| <TD WIDTH="7%" VALIGN="TOP"> </TD> | |
| <TD WIDTH="7%" VALIGN="TOP"> </TD> | |
| </TR> | |
| <TR><TD WIDTH="4%" VALIGN="TOP"> </TD> | |
| <TD WIDTH="81%" VALIGN="TOP"> | |
| <B><I><FONT FACE="Arial" SIZE=2><P>Specify</P> | |
| <P> </B></I></FONT></TD> | |
| <TD WIDTH="7%" VALIGN="TOP"> </TD> | |
| <TD WIDTH="7%" VALIGN="TOP"> </TD> | |
| </TR> | |
| <TR><TD WIDTH="4%" VALIGN="TOP"> | |
| <FONT FACE="Arial" SIZE=2><P ALIGN="CENTER">9</FONT></TD> | |
| <TD WIDTH="81%" VALIGN="TOP"> | |
| <FONT FACE="Arial" SIZE=2><P>ANY OTHER CONDITION THAT IS NOT ALREADY LISTED AND SHOULD BE DISCLOSED</FONT></TD> | |
| <TD WIDTH="7%" VALIGN="TOP"> </TD> | |
| <TD WIDTH="7%" VALIGN="TOP"> </TD> | |
| </TR> | |
| <TR><TD WIDTH="4%" VALIGN="TOP"> </TD> | |
| <TD WIDTH="81%" VALIGN="TOP"> | |
| <B><I><FONT FACE="Arial" SIZE=2><P>Specify</P> | |
| <P> </P> | |
| <P> </B></I></FONT></TD> | |
| <TD WIDTH="7%" VALIGN="TOP"> </TD> | |
| <TD WIDTH="7%" VALIGN="TOP"> </TD> | |
| </TR> | |
| <TR><TD WIDTH="4%" VALIGN="TOP"> | |
| <FONT FACE="Arial" SIZE=2><P ALIGN="CENTER"> </P> | |
| <P ALIGN="CENTER"> </FONT></TD> | |
| <TD WIDTH="81%" VALIGN="TOP"> | |
| <B><I><FONT FACE="Arial" SIZE=2><P> </P> | |
| <P>form completed by (print name):</B></I> _________________________________<B><I><U> </P> | |
| </U><P> </P> | |
| <P>signature:</B></I> ____________________________________________________</P> | |
| <B><I><P> </P> | |
| <P>relationship to participant: </B></I>______________________________________</P> | |
| <B><I><P> </P> | |
| <P>date: </B></I></FONT></TD> | |
| <TD WIDTH="7%" VALIGN="TOP"> </TD> | |
| <TD WIDTH="7%" VALIGN="TOP"> </TD> | |
| </TR> | |
| </TABLE> | |
| <B><I><FONT FACE="Arial" SIZE=2><P ALIGN="CENTER"> </P></B></I></FONT> | |
| <TABLE BORDER CELLSPACING=1 CELLPADDING=7 WIDTH=590> | |
| <TR><TD WIDTH="5%" VALIGN="TOP" BGCOLOR="#ffffff"> </TD> | |
| <TD WIDTH="80%" VALIGN="TOP" BGCOLOR="#ffffff"> | |
| <B><FONT FACE="Arial"><P ALIGN="CENTER">CONDITION</P> | |
| </B></FONT><I><FONT FACE="Arial" SIZE=1><P ALIGN="CENTER">This section must be completed by a </I></FONT><B><FONT FACE="Lucida Sans" SIZE=1>Physician, Physical Therapist, Occupational Therapist, or someone qualified to conduct Functional Assessments</B></FONT><I><FONT FACE="Arial" SIZE=1> of the participant </I></FONT></TD> | |
| <TD WIDTH="7%" VALIGN="TOP" BGCOLOR="#ffffff"> | |
| <B><FONT FACE="Arial" SIZE=2><P ALIGN="CENTER">NO</B></FONT></TD> | |
| <TD WIDTH="7%" VALIGN="TOP" BGCOLOR="#ffffff"> | |
| <B><FONT FACE="Arial" SIZE=2><P ALIGN="CENTER">YES</B></FONT></TD> | |
| </TR> | |
| <TR><TD WIDTH="5%" VALIGN="TOP"> | |
| <FONT FACE="Arial" SIZE=2><P ALIGN="CENTER">1</FONT></TD> | |
| <TD WIDTH="80%" VALIGN="TOP"> | |
| <FONT FACE="Arial" SIZE=2><P>SPINA BIFIDA</FONT></TD> | |
| <TD WIDTH="7%" VALIGN="TOP"> </TD> | |
| <TD WIDTH="7%" VALIGN="TOP"> </TD> | |
| </TR> | |
| <TR><TD WIDTH="5%" VALIGN="TOP"> | |
| <FONT FACE="Arial" SIZE=2><P ALIGN="CENTER">2</FONT></TD> | |
| <TD WIDTH="80%" VALIGN="TOP"> | |
| <FONT FACE="Arial" SIZE=2><P>CEREBRAL PALSY</FONT></TD> | |
| <TD WIDTH="7%" VALIGN="TOP"> </TD> | |
| <TD WIDTH="7%" VALIGN="TOP"> </TD> | |
| </TR> | |
| <TR><TD WIDTH="5%" VALIGN="TOP"> | |
| <FONT FACE="Arial" SIZE=2><P ALIGN="CENTER">3</FONT></TD> | |
| <TD WIDTH="80%" VALIGN="TOP"> | |
| <FONT FACE="Arial" SIZE=2><P>MUSCULAR DYSTROPHY</FONT></TD> | |
| <TD WIDTH="7%" VALIGN="TOP"> </TD> | |
| <TD WIDTH="7%" VALIGN="TOP"> </TD> | |
| </TR> | |
| <TR><TD WIDTH="5%" VALIGN="TOP"> | |
| <FONT FACE="Arial" SIZE=2><P ALIGN="CENTER">4</FONT></TD> | |
| <TD WIDTH="80%" VALIGN="TOP"> | |
| <FONT FACE="Arial" SIZE=2><P>HYDROCEPHALUS (SHUNT)</FONT></TD> | |
| <TD WIDTH="7%" VALIGN="TOP"> </TD> | |
| <TD WIDTH="7%" VALIGN="TOP"> </TD> | |
| </TR> | |
| <TR><TD WIDTH="5%" VALIGN="TOP"> | |
| <FONT FACE="Arial" SIZE=2><P ALIGN="CENTER">5</FONT></TD> | |
| <TD WIDTH="80%" VALIGN="TOP"> | |
| <FONT FACE="Arial" SIZE=2><P>VISUAL IMPAIRMENT</FONT></TD> | |
| <TD WIDTH="7%" VALIGN="TOP"> </TD> | |
| <TD WIDTH="7%" VALIGN="TOP"> </TD> | |
| </TR> | |
| <TR><TD WIDTH="5%" VALIGN="TOP"> | |
| <FONT FACE="Arial" SIZE=2><P ALIGN="CENTER">6</FONT></TD> | |
| <TD WIDTH="80%" VALIGN="TOP"> | |
| <FONT FACE="Arial" SIZE=2><P>POLIO</FONT></TD> | |
| <TD WIDTH="7%" VALIGN="TOP"> </TD> | |
| <TD WIDTH="7%" VALIGN="TOP"> </TD> | |
| </TR> | |
| <TR><TD WIDTH="5%" VALIGN="TOP"> | |
| <FONT FACE="Arial" SIZE=2><P ALIGN="CENTER">7</FONT></TD> | |
| <TD WIDTH="80%" VALIGN="TOP"> | |
| <FONT FACE="Arial" SIZE=2><P>AUTISM</FONT></TD> | |
| <TD WIDTH="7%" VALIGN="TOP"> </TD> | |
| <TD WIDTH="7%" VALIGN="TOP"> </TD> | |
| </TR> | |
| <TR><TD WIDTH="5%" VALIGN="TOP"> | |
| <FONT FACE="Arial" SIZE=2><P ALIGN="CENTER">8</FONT></TD> | |
| <TD WIDTH="80%" VALIGN="TOP"> | |
| <FONT FACE="Arial" SIZE=2><P>PREDISPOSITION TO SEIZURES</FONT></TD> | |
| <TD WIDTH="7%" VALIGN="TOP"> </TD> | |
| <TD WIDTH="7%" VALIGN="TOP"> </TD> | |
| </TR> | |
| <TR><TD WIDTH="5%" VALIGN="TOP"> | |
| <FONT FACE="Arial" SIZE=2><P ALIGN="CENTER">9</FONT></TD> | |
| <TD WIDTH="80%" VALIGN="TOP"> | |
| <FONT FACE="Arial" SIZE=2><P>USHER’S SYNDROME</FONT></TD> | |
| <TD WIDTH="7%" VALIGN="TOP"> </TD> | |
| <TD WIDTH="7%" VALIGN="TOP"> </TD> | |
| </TR> | |
| <TR><TD WIDTH="5%" VALIGN="TOP"> | |
| <FONT FACE="Arial" SIZE=2><P ALIGN="CENTER">10</FONT></TD> | |
| <TD WIDTH="80%" VALIGN="TOP"> | |
| <FONT FACE="Arial" SIZE=2><P>ANY OTHER CONDITION THAT COULD RESULT IN POSSIBLE LIMITATIONS DURING PARTICIPATION IN A GYMNASTIC CLASS</FONT></TD> | |
| <TD WIDTH="7%" VALIGN="TOP"> </TD> | |
| <TD WIDTH="7%" VALIGN="TOP"> </TD> | |
| </TR> | |
| <TR><TD WIDTH="5%" VALIGN="TOP"> </TD> | |
| <TD WIDTH="80%" VALIGN="TOP"> | |
| <B><I><FONT FACE="Arial" SIZE=2><P>Specify:</P> | |
| </B></I><P> </P> | |
| <P> </FONT></TD> | |
| <TD WIDTH="7%" VALIGN="TOP"> </TD> | |
| <TD WIDTH="7%" VALIGN="TOP"> </TD> | |
| </TR> | |
| <TR><TD WIDTH="5%" VALIGN="TOP"> | |
| <FONT FACE="Arial" SIZE=2><P ALIGN="CENTER">11</FONT></TD> | |
| <TD WIDTH="80%" VALIGN="TOP"> | |
| <FONT FACE="Arial" SIZE=2><P>DOWNS SYNDROME -if yes, please complete atlanto-axial section</FONT></TD> | |
| <TD WIDTH="7%" VALIGN="TOP"> </TD> | |
| <TD WIDTH="7%" VALIGN="TOP"> </TD> | |
| </TR> | |
| <TR><TD WIDTH="5%" VALIGN="TOP"> | |
| <FONT FACE="Arial" SIZE=2><P ALIGN="CENTER"> </P> | |
| <P ALIGN="CENTER"> </FONT></TD> | |
| <TD WIDTH="80%" VALIGN="TOP"> | |
| <B><I><FONT FACE="Arial" SIZE=2><P> </P> | |
| <P>form completed by (print name):</B></I> _________________________________</P> | |
| <B><I><P> </P> | |
| <P>signature: </B></I>____________________________________________________</P> | |
| <B><I><P> </P> | |
| <P>professional qualifications: </B></I>_____________________________________</P> | |
| <B><I><P> </P> | |
| <P>date:</B></I></FONT></TD> | |
| <TD WIDTH="7%" VALIGN="TOP"> </TD> | |
| <TD WIDTH="7%" VALIGN="TOP"> </TD> | |
| </TR> | |
| </TABLE> | |
| <B><U><FONT FACE="Arial" SIZE=4><P ALIGN="CENTER">FORM C</U>-</B></FONT><I><FONT FACE="Lucida Sans"> </FONT><B><U><FONT FACE="Arial">ABILITIES AND LIMITATIONS FORM</P> | |
| </U></FONT><FONT FACE="Lucida Sans" SIZE=2><P> </P> | |
| </I></FONT><FONT FACE="Arial" SIZE=2><P>NAME OF PARTICIPANT_______________________________________________________</P> | |
| <P>					 Activity permitted ?	</P></B></FONT> | |
| <TABLE BORDER CELLSPACING=1 CELLPADDING=7 WIDTH=590> | |
| <TR><TD WIDTH="48%" VALIGN="TOP"> | |
| <B><FONT FACE="Arial" SIZE=4><P ALIGN="CENTER">ACTIVITY</P> | |
| </B></FONT><I><FONT FACE="Arial" SIZE=1><P ALIGN="CENTER">This section is to be completed by a <B>parent, guardian, caregiver, councilor, physician, physical therapist, occupational therapist or educator/teacher</B> who is familiar with the ability level and limitations of the participant</I></FONT><B><U><FONT FACE="Lucida Sans" SIZE=1> </B></U></FONT></TD> | |
| <TD WIDTH="7%" VALIGN="TOP"> | |
| <B><FONT FACE="Arial" SIZE=2><P>YES</P> | |
| </B></FONT><FONT FACE="Arial" SIZE=1><P>-no limitations</FONT></TD> | |
| <TD WIDTH="8%" VALIGN="TOP"> | |
| <B><FONT FACE="Arial" SIZE=2><P>YES</B> </P> | |
| </FONT><FONT FACE="Arial" SIZE=1><P>-with assistance</FONT></TD> | |
| <TD WIDTH="7%" VALIGN="TOP" BGCOLOR="#ffffff"> | |
| <B><FONT FACE="Arial" SIZE=2><P>NO</B></FONT></TD> | |
| <TD WIDTH="30%" VALIGN="TOP"> | |
| <B><FONT FACE="Arial" SIZE=2><P>COMMENTS</B></FONT></TD> | |
| </TR> | |
| <TR><TD WIDTH="48%" VALIGN="TOP"> | |
| <FONT FACE="Arial" SIZE=2><P>WEIGHT BEARING ON FEET</FONT></TD> | |
| <TD WIDTH="7%" VALIGN="TOP"> </TD> | |
| <TD WIDTH="8%" VALIGN="TOP"> </TD> | |
| <TD WIDTH="7%" VALIGN="TOP" BGCOLOR="#ffffff"> </TD> | |
| <TD WIDTH="30%" VALIGN="TOP"> </TD> | |
| </TR> | |
| <TR><TD WIDTH="48%" VALIGN="TOP"> | |
| <FONT FACE="Arial" SIZE=2><P>WEIGHT BEARING ON HANDS & KNEES</FONT></TD> | |
| <TD WIDTH="7%" VALIGN="TOP"> </TD> | |
| <TD WIDTH="8%" VALIGN="TOP"> </TD> | |
| <TD WIDTH="7%" VALIGN="TOP" BGCOLOR="#ffffff"> </TD> | |
| <TD WIDTH="30%" VALIGN="TOP"> </TD> | |
| </TR> | |
| <TR><TD WIDTH="48%" VALIGN="TOP"> | |
| <FONT FACE="Arial" SIZE=2><P>WEIGHT BEARING STOMACH (PRONE)</FONT></TD> | |
| <TD WIDTH="7%" VALIGN="TOP"> </TD> | |
| <TD WIDTH="8%" VALIGN="TOP"> </TD> | |
| <TD WIDTH="7%" VALIGN="TOP" BGCOLOR="#ffffff"> </TD> | |
| <TD WIDTH="30%" VALIGN="TOP"> </TD> | |
| </TR> | |
| <TR><TD WIDTH="48%" VALIGN="TOP"> | |
| <FONT FACE="Arial" SIZE=2><P>WEIGHT BEARING BACK (SUPINE)</FONT></TD> | |
| <TD WIDTH="7%" VALIGN="TOP"> </TD> | |
| <TD WIDTH="8%" VALIGN="TOP"> </TD> | |
| <TD WIDTH="7%" VALIGN="TOP" BGCOLOR="#ffffff"> </TD> | |
| <TD WIDTH="30%" VALIGN="TOP"> </TD> | |
| </TR> | |
| <TR><TD WIDTH="48%" VALIGN="TOP"> | |
| <FONT FACE="Arial" SIZE=2><P>WEIGHT BEARING HANDS (ie handstand)</FONT></TD> | |
| <TD WIDTH="7%" VALIGN="TOP"> </TD> | |
| <TD WIDTH="8%" VALIGN="TOP"> </TD> | |
| <TD WIDTH="7%" VALIGN="TOP" BGCOLOR="#ffffff"> </TD> | |
| <TD WIDTH="30%" VALIGN="TOP"> </TD> | |
| </TR> | |
| <TR><TD WIDTH="48%" VALIGN="TOP"> | |
| <FONT FACE="Arial" SIZE=2><P>HANGING/SWINGING FROM HANDS</FONT></TD> | |
| <TD WIDTH="7%" VALIGN="TOP"> </TD> | |
| <TD WIDTH="8%" VALIGN="TOP"> </TD> | |
| <TD WIDTH="7%" VALIGN="TOP" BGCOLOR="#ffffff"> </TD> | |
| <TD WIDTH="30%" VALIGN="TOP"> </TD> | |
| </TR> | |
| <TR><TD WIDTH="48%" VALIGN="TOP"> | |
| <FONT FACE="Arial" SIZE=2><P>JUMPING/SPRINGING ON MATS</FONT></TD> | |
| <TD WIDTH="7%" VALIGN="TOP"> </TD> | |
| <TD WIDTH="8%" VALIGN="TOP"> </TD> | |
| <TD WIDTH="7%" VALIGN="TOP" BGCOLOR="#ffffff"> </TD> | |
| <TD WIDTH="30%" VALIGN="TOP"> </TD> | |
| </TR> | |
| <TR><TD WIDTH="48%" VALIGN="TOP"> | |
| <FONT FACE="Arial" SIZE=2><P>JUMPING (BOUNCING) ON TRAMPOLINE</FONT></TD> | |
| <TD WIDTH="7%" VALIGN="TOP"> </TD> | |
| <TD WIDTH="8%" VALIGN="TOP"> </TD> | |
| <TD WIDTH="7%" VALIGN="TOP" BGCOLOR="#ffffff"> </TD> | |
| <TD WIDTH="30%" VALIGN="TOP"> </TD> | |
| </TR> | |
| <TR><TD WIDTH="48%" VALIGN="TOP"> | |
| <FONT FACE="Arial" SIZE=2><P>BOUNCING ON SEAT -TRAMP</FONT></TD> | |
| <TD WIDTH="7%" VALIGN="TOP"> </TD> | |
| <TD WIDTH="8%" VALIGN="TOP"> </TD> | |
| <TD WIDTH="7%" VALIGN="TOP" BGCOLOR="#ffffff"> </TD> | |
| <TD WIDTH="30%" VALIGN="TOP"> </TD> | |
| </TR> | |
| <TR><TD WIDTH="48%" VALIGN="TOP"> | |
| <FONT FACE="Arial" SIZE=2><P>ROLLING forward or backward over neck</FONT></TD> | |
| <TD WIDTH="7%" VALIGN="TOP"> </TD> | |
| <TD WIDTH="8%" VALIGN="TOP"> </TD> | |
| <TD WIDTH="7%" VALIGN="TOP" BGCOLOR="#ffffff"> </TD> | |
| <TD WIDTH="30%" VALIGN="TOP"> </TD> | |
| </TR> | |
| <TR><TD WIDTH="48%" VALIGN="TOP"> | |
| <FONT FACE="Arial" SIZE=2><P>ROLLING longitudinal (ie-log rolling)</FONT></TD> | |
| <TD WIDTH="7%" VALIGN="TOP"> </TD> | |
| <TD WIDTH="8%" VALIGN="TOP"> </TD> | |
| <TD WIDTH="7%" VALIGN="TOP" BGCOLOR="#ffffff"> </TD> | |
| <TD WIDTH="30%" VALIGN="TOP"> </TD> | |
| </TR> | |
| <TR><TD WIDTH="48%" VALIGN="TOP"> | |
| <FONT FACE="Arial" SIZE=2><P>OTHER</FONT></TD> | |
| <TD WIDTH="7%" VALIGN="TOP"> </TD> | |
| <TD WIDTH="8%" VALIGN="TOP"> </TD> | |
| <TD WIDTH="7%" VALIGN="TOP" BGCOLOR="#ffffff"> </TD> | |
| <TD WIDTH="30%" VALIGN="TOP"> </TD> | |
| </TR> | |
| </TABLE> | |
| <B><FONT FACE="Arial" SIZE=1><P>I FEEL THAT GYMNASTICS WOULD BE BENEFICIAL FOR THE APPLICANT. THE FOLLOWING LIMITATIONS, IF ANY, SHOULD BE TAKEN INTO CONSIDERATION WHEN DESIGNING A PROGRAM FOR THIS INDIVIDUAL. (IE RANGE OF MOTION, SPECIAL DEVICES...)</P> | |
| </FONT><FONT FACE="Lucida Sans" SIZE=2><P>_________________________________________________________________________________</P> | |
| <P>_________________________________________________________________________________</P> | |
| </FONT><FONT FACE="Arial" SIZE=1><P> </P> | |
| <P>3) IF AN ASSISTANT IS RECOMMENDED BY THE CLUB, WHO WILL BE ACCOMPANYING THE PARTICIPANT?</P> | |
| </FONT><FONT FACE="Lucida Sans" SIZE=2><P> </P> | |
| </B></FONT><FONT FACE="Arial" SIZE=1><P>Name____________________________________ Professional occupation (if applicable)________________________</P> | |
| <P>Does the assistant represent an outside institution, agency or organization? No___Yes___ If yes, please </P> | |
| <P>specify___________________________________________________________________________________________</P> | |
| <B><P> </P> | |
| <P>PERSON COMPLETING THIS FORM_________________________________________DATE</FONT><FONT FACE="Lucida Sans" SIZE=2>___________________</P> | |
| <P> </P> | |
| </B></FONT><FONT FACE="Arial" SIZE=2><P>------------------------------------------------------</FONT><I><FONT FACE="Arial" SIZE=1>CLUB USE</I></FONT><FONT FACE="Arial" SIZE=2>----------------------------------------------------------</P> | |
| <B><U><P ALIGN="CENTER"> </P> | |
| <P ALIGN="CENTER">CLUB TECHNICAL ADVISOR’S RECOMMENDATIONS</P> | |
| </B></U><P>1) REQUIRES ASSISTANT no____ yes____</P> | |
| <P>2) CONSIDERATIONS___________________________________________________________</P> | |
| <P> </P> | |
| <P>___________________________________________________________________________ </P> | |
| <P> </P> | |
| <P>3) LIMITATIONS_______________________________________________________________</P> | |
| <P> </P> | |
| <P>_____________________________________________________________________________</P> | |
| <P> </P> | |
| <P>4) SPECIAL EQUIPMENT RECOMMENDATIONS_____________________________________</P> | |
| <P> </P> | |
| <P>_____________________________________________________________________________</P> | |
| <P> </P> | |
| <P>5) ADDITIONAL COMMENTS_____________________________________________________</P> | |
| <P> </P> | |
| <P>_____________________________________________________________________________</P> | |
| <P> </P> | |
| </FONT><B><I><FONT FACE="Arial" SIZE=1><P>TECHNICAL ADVISOR____________________________________________DATE_________________</P> | |
| </I></FONT><FONT FACE="Lucida Sans" SIZE=2><P> </P> | |
| </FONT><U><FONT FACE="Arial" SIZE=4><P ALIGN="CENTER">Notice to all Downs syndrome participants:</P> | |
| <P ALIGN="CENTER"> </P> | |
| </B></U></FONT><FONT FACE="Arial" SIZE=2><P>According to the Ontario Special Olympics, participation in gymnastics and similar activities by those individuals who have a positive gap greater than or equal to .5 cm in the C1 and C2 vertebrae in the neck, could potentially result in "injury if they participate in activities that hyper-extend or radically flex the neck or upper spine." As a result of this recommendation, The Ontario Gymnastic Federation requires all participants with Downs syndrome, who are potentially pre-disposed to this condition, to be x-rayed, in order to determine whether or not this condition is present. Should the gap be greater than .5 cm, for the safety of the individual, The Ontario Gymnastic Federation prohibits participation by this individual in any gymnastic activity.</P> | |
| </FONT><B><U><FONT FACE="Arial" SIZE=4><P ALIGN="CENTER"> </P> | |
| </B></U></FONT><FONT SIZE=2><P ALIGN="CENTER"></P> | |
| </FONT><B><U><FONT FACE="Arial" SIZE=4><P ALIGN="CENTER">ATLANTO-AXIAL DISLOCATION EXAMINATION RESULT FORM</P> | |
| </U></FONT><FONT FACE="Arial" SIZE=2><P ALIGN="CENTER">NOTE: ALL DOWNS SYNDROME APPLICANTS </P> | |
| <P ALIGN="CENTER">MUST HAVE THE FOLLOWING SECTION COMPLETED BY THEIR DOCTOR</P> | |
| <P ALIGN="CENTER"> </P> | |
| <P>This is to certify that________________________________ who has Downs Syndrome, has had x-rays taken (full extension and flexion of the neck) to determine a pathological displacement of C1 on C2. </P> | |
| <P>DATE OF X-RAY____________________________</P> | |
| <U><P> </P> | |
| <P>RESULTS</P> | |
| </U><P>Positive – C1 - C2 gap distance equal to or greater than .5</P> | |
| <P>Negative – C1 - C2 gap distance less than .5</P> | |
| <P> </P> | |
| <P>(please circle) Positive/Negative & indicate gap distance: ____________cm</P> | |
| <P> </P> | |
| <P> </P> | |
| </B><P>Physician’s Name_______________________________ Phone____________________</P> | |
| <P> </P> | |
| <P>Signature____________________________________ Date____________________________</P> | |
| <B><P ALIGN="CENTER"> </P> | |
| <P ALIGN="CENTER"> </P> | |
| <P ALIGN="CENTER"> </P> | |
| <P ALIGN="CENTER"> </P> | |
| <P ALIGN="CENTER"> </P> | |
| <P ALIGN="CENTER"> </P> | |
| <P ALIGN="CENTER"> </P> | |
| <P ALIGN="CENTER"> </P> | |
| </FONT><U><FONT FACE="Arial" SIZE=4><P ALIGN="CENTER"> </P> | |
| <P ALIGN="CENTER">CLUB APPLICATION TO OFFER SPECIAL NEEDS PROGRAMS</P> | |
| </U></FONT><FONT FACE="Arial" SIZE=2><P> </P> | |
| <P>CLUB NAME_______________________________________________________________</P> | |
| <P> </P> | |
| <P>ADDRESS_________________________________________________________________</P> | |
| <P> </P> | |
| <P>PHONE__________________________________FAX_________________________________</P> | |
| <P> </P> | |
| <P> </P> | |
| <P>1) SPECIAL NEEDS CLUB CONTACT___________________________________________ __ </P> | |
| <P> </P> | |
| <P>PHONE_________________________Signature_____________________________________</P> | |
| <P> </P> | |
| <P>2) (one required) </P> | |
| <P> </P> | |
| <P>SPECIAL NEEDS TECHNICAL ADVISOR________________________________________</P> | |
| <P> </P> | |
| <P>QUALIFICATIONS______________________________________________________________</P> | |
| <P> </P> | |
| <P>PHONE________________________________Signature______________________________</P> | |
| <P> </P> | |
| <P> </P> | |
| <P>SPECIAL NEEDS TECHNICAL ADVISOR________________________________________</P> | |
| <P> </P> | |
| <P>QUALIFICATIONS______________________________________________________________</P> | |
| <P> </P> | |
| <P>PHONE________________________________Signature______________________________</P> | |
| <P> </P> | |
| <P> </P> | |
| <P> </P> | |
| <P>SPECIAL NEEDS TECHNICAL ADVISOR________________________________________</P> | |
| <P> </P> | |
| <P>QUALIFICATIONS______________________________________________________________</P> | |
| <P> </P> | |
| <P>PHONE________________________________Signature______________________________</P> | |
| <P> </P> | |
| <P> </P> | |
| <P> </P> | |
| <P>3) SPECIAL NEEDS HEAD COACH________________________________________________</P> | |
| <P> </P> | |
| <P>NCCP QUALIFICATIONS________________________________________________________</P> | |
| <P> </P> | |
| <P>PHONE____________________________________Signature__________________________</P> | |
| <P> </P> | |
| </B></FONT><FONT FACE="Lucida Sans" SIZE=2><P>DATE OF APPLICATION______________________________________________________________</P> | |
| <P ALIGN="CENTER"> </P> | |
| </FONT><FONT FACE="Arial" SIZE=2><P ALIGN="CENTER"> </P></FONT></BODY> | |
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