EMERGENCY INFORMATION: (COntaCt information
MOVING MOUNTAINS ADAPTIVE PROGRAM REGISTRATION FORM
PARTICIPANT
INFORMATION
NAME
Veteran? Y
N
EMAIL
Military
Branch
and
Rank
:
PHONE NUMBER (W)
ADDRESS
D
OB
STATE
AGE
MALE
FEMALE
WEIGHT
HEIGHT
ZIP
SHOE SIZE
EMERGENCY INFORMATION: (COntaCt information for the time of the scheduled lesson)
EMERGENCY
CONTACT
PERSON
PHONE 椅臆漢
PARENT INFO則MATION: (If participant is under 21)
PH ONE(W)
PARENT NAME
Please indicate if you would like to be called on short notice if a lesson sIot is available: yeS nO
Contact infomation to alert you to lesson availability (email and/or phone):
MEDICAL INFORMATION : DATE OF ONSET
PARTICIPANT’S DISABILITY
DOES
STUDENT
USE
A
WHEELCHAIR? Y
lSSTUDENTABLETOWALK? Y
N %
OF
N %OFTIME
TIME
ENJURY/LESION
LEVEL
MOBILITYAIDS
DOES STUDENT FATIQUE AFTER TRAVELLENG DISTANCES? Y N CAN
BALANCE
BE
AN
ISSUE
WHEN
WALKING? Y
N
DOES STUDENTNEED SUPPORTFROMMID-LEVELCHESTANDUP? Y N
DOES STUDENT LEAN? LEFT, RIGHT, NEITHER
DOESSTUDENTHAVESEIZURES? Y N
DATE OF MOST RECENT SEIZURE WHAT HAPPENS BEFORE THE SEIZURE WHAT HAPPENS DURING THE SEIZURE
DOES STUDENT HAVE DIFFICULTY WITH ANXIETY/ANXIOUS SITUATIONS? Y N
PLEASE DESCRIBE
IS
STUDENT
CURRENTLY
TAKING
ANY
MEDICATIONS? YES
NO
LIST MEDICATIONS AND PURPOSE
DEAF/HARD OF HEARENG? DOES STUDENT USE HEARING AIDS? Y N
DOES STUDENT USE SIGN LANGUAGE? Y N
BLIND/VISUALLY
IMPAIRED? Y
N
TYPE
OF
VISION
LOSS
IF NON-VERBAL, CAN STUDENT COMMUNICATE VIA A DIFFERENT MEANS? Y N
IF YES, PLEASE DESCRIBE
IS STUDENT CURRENTLY UNDER A PHYSICIAN’S CARE FOR ANY REASON? Y N
EXPLAIN
PLEASE LIST FOOD, MEDICATION OR ANY OTHER ALLERGIES
LATEXALLERGY? Y
N
DOES STUDENT HAVE ANY SPECIFIC CONDITIONS WE SHOULD BE AWARE OF? Y N
(Diabetes, heart trouble, SPinal stabilization, Sh肌tS, asthma, Catheter, etC…)
SKILL LEVEL INFORMATION: SKIED/SNOWBOARDED
BEFORE? Y
DOES
OF
STUDENT
OWN
DETAILS
COMPLETED BY:
SIGN AND DATE:
ANY
THE
N
SKIED/SNOWBOARDED
EQUIPMENT
TO
BE
USED
DURING
SENCEINJURY? Y
THE
LESSON? Y
N
N
WHEN?
PARTICIPANT
INFORMATION
NAME
Veteran? Y
N
Military
Branch
and
Rank
:
PHONE NUMBER (W)
ADDRESS
D
OB
STATE
AGE
MALE
FEMALE
WEIGHT
HEIGHT
ZIP
SHOE SIZE
EMERGENCY INFORMATION: (COntaCt information for the time of the scheduled lesson)
EMERGENCY
CONTACT
PERSON
PHONE 椅臆漢
PARENT INFO則MATION: (If participant is under 21)
PH ONE(W)
PARENT NAME
Please indicate if you would like to be called on short notice if a lesson sIot is available: yeS nO
Contact infomation to alert you to lesson availability (email and/or phone):
MEDICAL INFORMATION : DATE OF ONSET
PARTICIPANT’S DISABILITY
DOES
STUDENT
USE
A
WHEELCHAIR? Y
lSSTUDENTABLETOWALK? Y
N %
OF
N %OFTIME
TIME
ENJURY/LESION
LEVEL
MOBILITYAIDS
DOES STUDENT FATIQUE AFTER TRAVELLENG DISTANCES? Y N CAN
BALANCE
BE
AN
ISSUE
WHEN
WALKING? Y
N
DOES STUDENTNEED SUPPORTFROMMID-LEVELCHESTANDUP? Y N
DOES STUDENT LEAN? LEFT, RIGHT, NEITHER
DOESSTUDENTHAVESEIZURES? Y N
DATE OF MOST RECENT SEIZURE WHAT HAPPENS BEFORE THE SEIZURE WHAT HAPPENS DURING THE SEIZURE
DOES STUDENT HAVE DIFFICULTY WITH ANXIETY/ANXIOUS SITUATIONS? Y N
PLEASE DESCRIBE
IS
STUDENT
CURRENTLY
TAKING
ANY
MEDICATIONS? YES
NO
LIST MEDICATIONS AND PURPOSE
DEAF/HARD OF HEARENG? DOES STUDENT USE HEARING AIDS? Y N
DOES STUDENT USE SIGN LANGUAGE? Y N
BLIND/VISUALLY
IMPAIRED? Y
N
TYPE
OF
VISION
LOSS
IF NON-VERBAL, CAN STUDENT COMMUNICATE VIA A DIFFERENT MEANS? Y N
IF YES, PLEASE DESCRIBE
IS STUDENT CURRENTLY UNDER A PHYSICIAN’S CARE FOR ANY REASON? Y N
EXPLAIN
PLEASE LIST FOOD, MEDICATION OR ANY OTHER ALLERGIES
LATEXALLERGY? Y
N
DOES STUDENT HAVE ANY SPECIFIC CONDITIONS WE SHOULD BE AWARE OF? Y N
(Diabetes, heart trouble, SPinal stabilization, Sh肌tS, asthma, Catheter, etC…)
SKILL LEVEL INFORMATION: SKIED/SNOWBOARDED
BEFORE? Y
DOES
OF
STUDENT
OWN
DETAILS
COMPLETED BY:
SIGN AND DATE:
ANY
THE
N
SKIED/SNOWBOARDED
EQUIPMENT
TO
BE
USED
DURING
SENCEINJURY? Y
THE
LESSON? Y
N
N
WHEN?
