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Adaptive Sports Association Participant Intake
Winter 2017-18
Contact Information
First name:
Your answer
Last name:
Your answer
Date of birth:
MM
/
DD
/
YYYY
Street address:
Your answer
City:
Your answer
State:
Your answer
Zip:
Your answer
Cell phone:
XXX-XXX-XXXX
Your answer
Home phone:
XXX-XXX-XXXX
Your answer
Work phone:
XXX-XXX-XXXX
Your answer
E-mail:
Your answer
Gender:
Age:
Your answer
Height:
Your answer
Weight:
Your answer
Shoe size:
Your answer
Are you your own legal guardian? *
If the answer is NO, your legal guardian or legal representative must sign the waiver & release of liability agreement on your behalf.
Please provide the following information about your guardian:
Guardian's full name
Your answer
Guardian's relationship to you
Your answer
Where are you staying in Durango?
Your answer
What name is your room under?
Your answer
What's the lodge's phone number?
XXX-XXX-XXX
Your answer
Emergency contact- full name, relationship, phone no. *
Your answer
Dates of ski lesson
Your answer
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