HomeMy WebLinkAboutKeiki Triathlon Flyer and Registration Form 2014
County of Hawai‘i Department of Parks and Recreation
& Hawai‘i Isle Police Activities League (HI-PAL)
3rd Annual
KEIKI TRIATHLON
October 18, 2014
MakaÔeo Park (Kona Old Airport)
Kona Community Aquatic Center
This event is being held in conjunction with Mayor Billy Kenoi’s Annual Health Fest
Children ages 7-14 years old are invited and encouraged to participate in
events similar to the IRONMAN World Championships held one week earlier.
Age Group: 7-8
50 yard Swimming ~ 1.6 Mile Bicycling ~ 1/2 Mile Running
Age Groups: 9-10, 11-12 and 13-14
100 yard Swimming ~ 3.2 Mile Bicycling ~ 1 Mile Running
Entry Fee: $5.00 per child
Entries will be limited to the first 30 children in each of the four age-group categories
or a maximum of 120 total racers to ensure the safety of the athletes.
***ENTRY DEADLINE is Friday, OCTOBER 3, 2014***
Please mail or bring entries to the Recreation Division, 799 Pi‘ilani Street, Hilo, HI 96720.
All participants must supply their own bicycle, helmet, swim goggles and other equipment.
Medals will be awarded to the top three finishers, both boys and girls, in each age category.
All finishers will receive commemorative certificates.
Racers must check-in by 7:30 a.m. on the day of the race October 18th. The triathlon will begin
promptly at 8:00 a.m. with the youngest children entering the pool at 8:00 a.m.
Entry forms are available online http://www.hawaiicounty.gov/pr-recreation/, at the
Recreation Division Office located in Aunty Sally Kaleohano Luau Hale, 799 Pi‘ilani Street or at
all islandwide Recreation Division facilities, Aquatic pools and at the following locations:
Kekuaokalani Gym ~ 327-3553, Waikoloa Pu‘u Nui Park ~ 883-6100
Waimea Community Center ~ 887-3014, Hisaoka Gym ~ 889-6505
For more information, contact Jason Armstrong, Public Information Officer, at 345-9105 or email
jarmstrong@hawaiicounty.gov, or Darrell Yamamoto cell 938-2012 or email darrell.yamamoto@hawaiicounty.gov.
POLICY OF NON-DISCRIMINATION ON THE BASIS OF DISABILITY
The Department of Parks and Recreation provides recreational opportunities without regard to race, color,
national origin, age, sex, religion or disability. Please call Alisa Mitchener, Recreation Specialist, at 961-8681
to discuss your need for reasonable accommodation or for more information on site accessibility.
COUNTY OF HAWAII
DEPARTMENT OF PARKS AND RECREATION
REGISTRATION FORM / CONSENT / RELEASE OF CLAIMS
Date Form Filled Out 20
DISTRICT West Hawaii EVENT DATE Oct. 18, 2014 FACILITY Maka'eo Park & Kona Community Aquatic Center
SPORT/ACTIVITY 2014 Keiki Triathlon AGE GROUP Please circle one: 7-8 yr. 9-10 yr. 11-12 yr. 13-14 yr.
PARTICIPANT'S NAME
GENERAL INFORMATION (Please Print)
(Last) (First) (Ml)
AGE BIRTHDATE
PARENT/LEGAL GUARDIAN PHONE (home)
(Last) (First) (Ml)
MAILING ADDRESS
SCHOOL
PHONE
PHONE
GRADE
(work)
(cell)
HEALTH & EMERGENCY INFORMATION
PLEASE LET US KNOW ANY MEDICAL INFORMATION RELEVANT TO THE CARE OF YOUR CHILD:
CHILD'S DOCTOR PHONE HEALTH PLAN
EMERGENCY CONTACTS other than parent/guardian listed above:
NAME PHONE RELATIONSHIP
NAME PHONE RELATIONSHIP
We are committed to making our recreation programs accessible. Does your child need modifications due to a
disability to effectively participate in our program? Please Check One: YES NO
L� If yes, please complete a Modification Request with our Recreation Specialist, ph. 961-8740 ext .24, TTY 961-8736.
Adult attendants or skills trainers who accompany a child in our P&R programs must register before the first day of the program.
MEDIA RELEASE
I/We hereby give permission to the Department of Parks & Recreation, County of Hawaii, to allow the news media to film and
photograph program activities provided: 1) They are for news and non-commercial purposes; 2) The program director determines the
filming, etc., will not unduly interfere with or disturb the programs; and 3) Individual children are not singled out for demonstrating
photography or interview purposes against their wishes.
Please Check One: YES, permission granted NO, permission denied
(If no box is checked, assumption is "No, permission denied")
CONSENT
In consideration of the permission granted to me by the County of Hawaii, State of Hawaii, for my minor child
("Child") to participate in the above-mentioned sport/activity ("Activity"), the above-named PARENT/LEGAL
GUARDIAN ("Parent") consents and agrees that:
a. Child is allowed to actively participate in Activity;
b. Child is participating voluntarily, and with Parent's approval and consent.
c. Child is in reasonably good physical and mental health, such that Minor can safely participate in Activity.
d. Parent recognizes and understands that participation in the Activity involves risk of death, personal
injury and/or property damages, commonly inherent in such Activity.
e. Parent shall notify a representative from the Department of Parks and Recreation if there is any change
in Child's physical and/or mental condition such that MINOR cannot safely participate in Activity.
f. The Department of Parks & Recreation may refer Child, if injured or ill, to my family doctor when I cannot
be reached. When there is no family doctor, the Department has the discretion to select a doctor.
I also agree: 1. I have read BOTH SIDES of this registration form, including the Informed Consent,
Assumption of Risks, Code of Conduct, and Release of Claims on the back side of this page.
2. 1 understand and agree with all of its terms.
3. 1 have filled out the information on this form fully and completely.
4. 1 will notify the County immediately in writing of any changes to the information above.
5. 1 am signing this form voluntarily and with full knowledge of its significance.
IN WITNESS WHEREOF, I have executed this Registration, Consent and Assumption of Risks, Release of Claims
and Indemnification and Code of Conduct at on the day and year first written above.
(Place of Execution)
Signature of Witness (Age 18 or Older)
Printed Name of Witness
Phone Number
Address City Zip Code
Rev 5/23-06
Signature of Parent or Legal Guardian
Possession or consumption of alcohol by persons under 21 is prohibited.
County of Hawaii is an Equal Opportunity Provider and Employer
INFORMED CONSENT AND ASSUMPTION OF RISKS
The Department of Parks and Recreation provides a wide variety of activities and programs for persons of all ages in a safe and
pleasant environment. However, there are certain inherent risks in almost every activity. Please read the following informed
consent categories to acquaint yourself with the risks involved. If you are making a determination that you child is able to
participate in any activity, it is your responsibility to assess your child's maturity, health/fitness and ability to obey safety rules and
decide if the risks associated with these activities are acceptable to you. While the County of Hawai`i hopes that every participant
enjoys an injury-free activity, by your signing this Release of Claims form, you assume all risks associated with the activity for
which you have registered your child. Please ask any questions of the instructor which you may need to make a fully informed
decision for your child to participate.
Certain sport activities, such as football, basketball, baseball and volleyball may have physical contact. All contact sports
necessarily and unavoidably carry with them the risk of high speed collisions with other persons, balls, and equipment. In addition,
irregular playing surfaces may be present and a child may be at risk for falling or minor lacerations. There are, therefore, risks of
orthopedic, dental, cervical, spinal, head or other types of injury. lacerations and other injury from
There is also the risk of
falling and/or colliding with people or objects.
In addition, all sports require a level of fitness and health that only your physician can determine you or your child possesses. We
strongly urge that you obtain medical advice as to whether contact sport activities are suitable for your child`.
Many
undetected or chronic diseases such as cardiac disease or high blood pressure may be worsened by participation in these
activities.
Activities such as ceramics, painting, or cooking are examples of types of activities which may involve supplies or ingredients
allergic reactions or
which may be toxic when ingested, inhaled or when coming in contact with skin. There may also be
individual sensitivity to these supplies or ingredients when ingested, inhaled, or when in contact with skin.
Swimming at the beach or pool is another activity with inherent risks involved.
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RELEASE OF CLAIMS AND INDEMNIFICATION
In consideration of permission granted to participant by the County of Hawai`i, Department of Parks and Recreation, to participate
in the activities listed on the previous page:
I/we hereby release the County of Hawai`i, its agents, employees, and independent contractors from all actions, causes of action,
damages, claims, or demands which I, my heirs, personal representatives, or assignees may have against the County of Hawai`i,
and other above-named parties for all injuries, known or unknown, which may incur by my childs participation in the above-
described activity or by my childs use of the above-described Facility.
I/we do further agree that I shall indemnify and save harmless the County of Hawai`i, or any of its officers or employees, either
jointly or severally, from any and all claims, demands, damages, loss of service, or expense for property damage and for personal
injuries or actions brought by a third party resulting or arising from my childs participation in the above-described activity or my
childs use of the Facility.
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PARTICIPANTS & PARENTS CODE OF CONDUCT
1. I will encourage, but not force, my child to participate in any program or event.
2. I will remember that children participate to have fun, and that the program/event is for youth, not adults.
3. I will pay close attention to the physical conditioning and well-being of my child, and will refuse to jeopardize the health of
any individual for the sake of improving a persons or teams chance to win.
4. I will not ridicule or yell at my child or any other participant for making a mistake or losing.
5. I (& guests) will be positive role models for my child, and encourage sportsmanship by showing respect and courtesy, and
by demonstrating positive support for all staff, players, coaches, officials, and spectators at every game, practice,
tournament, or event.
6. I will respect officials and their decisions. I will not argue with an official in public, and will not yell, swear or be verbally
abusive. Any discussion or constructive comment shall be done in an unemotional and calm manner.
7. I will not engage in any physical or verbal confrontation or altercation before, during or after any program, game or event,
with officials, coaches, players, staff, or spectators. Doing so shall result in immediate action by the police and the
Director of the Department of Parks & Recreation.
8. All P&R Activities are drug and alcohol free for participants and adults. Anyone found to be under the influence,
intoxicated, or in possession of any of these will be TERMINATED from participating in the program. The Police and the
Director of the Department of Parks & Recreation will be notified.
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I have read and understand the Informed Consent and Assumption of Risks, Release of Claims and Indemnification, and Code of
Conduct on this page 2.
_____________________________________________
Signature of Parent/Legal Guardian