Please provide the following information so that we can assist you in setting up an Adaptive Lesson:
** Required Fields

**Name:
# of years skiing/snowboarding:
Address:
City:
State:
Zip Code:
**Primary Phone #:
Secondary Phone #:
**Email:
Best way to reach you (phone / email):
Date of birth (mm/dd/yyyy):
Gender:
Height:
Shoe Size:
Weight:
Physician’s Name::
Physician’s Phone #:
EMERGENCY CONTACT INFO OR PARENT-GUARDIAN CONTACT INFO (if participant is a minor)
EC or Parent Name(s)::
EC or Home Phone:
EC or Parent Work/Cell Phone:
EC or Parent Email:
MEDICAL INFORMATION
Description of Participant’s disability:
What major life function(s) does Participant’s disability affect:
Participant’s current activities / general energy level:
List medications Participant is currently taking:
Has the Participant experienced a seizure within the past year?:
If so please indicate the approx. date of last seizure:
List Participant’sfood/medication allergies:
Does Participant need to limit their activities for any reason?:
Please check most appropriate answer:
Ability to sense cold:	Normal Impaired Unable
Comprehension:	Normal Impaired Unable
Hearing / Vision level:	Normal Impaired Unable
Verbal Communication:	Normal Impaired Unable
INDICATE PARTICIPATION PREFERENCES BELOW
**Date of lesson (mm/dd/yyyy):
Lesson Time:
FIRST CHOICE 9:00am 1 hour 12:00 – 2:00pm 2 hour
SECOND CHOICE 9:00am 1 hour 12:00 – 2:00pm 2 hour
Please provide special requests or additional information we should know:

Equipment Needs – PLEASE INDICATE TO THE BEST OF YOUR ABILITY:
	Outriggers with standard equipment — Outriggers are handheld crutches with mini-skis on each end. Outriggers are for any stand up skier requiring extra balance:
	Bi-Ski (weight must not exceed 185 lbs.) This sit down ski is forwheelchair users or those who have significant difficulty walking:
	Mono-Ski (skier weight must not exceed 185 lbs.)This sit down ski is for spinal cord injuries
	Standard Equipment (boots, poles and skis) :
	Helmet:

THIS SECTION TO BE FILLED OUT BY SIT DOWN SKIERS ONLY
Will rolling onto your shoulders cause pain to your back or shoulders?:	Yes No
Using arm strength, can you push your own wheelchair independently?:	Yes No
Do you have Harrington Rods or a shunt?:	Yes No
If applicable, please note the level of your spinal cord injury:
Do you have the ability to maintain grip strength in your hands?:	Yes No