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Summer Participant Intake
This form is for individuals wishing to participate in Adaptive Sports Association Summer 2021 programs. If you are a military veteran or active duty personnel, please complete our Military Veteran Intake.
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* Indicates required question
Are you a new or returning participant to Adaptive Sports Association?
*
New
Returning
Participant First Name
*
Your answer
Participant Last Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Age
*
Your answer
I identify my/the participant's ethnicity as:
*
Select all that apply.
Asian
Black/African
White/Caucasian
Hispanic/Latino
Native American
Pacific Islander
Prefer not to answer
Other:
Required
What is your gender?
*
Your answer
Cell Phone
*
(XXX) XXX-XXXX
Your answer
Home Phone
(XXX) XXX-XXXX
Your answer
Work Phone
(XXX) XXX-XXXX
Your answer
Email
*
Your answer
Emergency Contact Name
*
Your answer
Emergency Contact Phone Number
*
(XXX) XXX-XXXX
Your answer
Emergency Contact Relationship
*
Your answer
Participant Street Address
*
Your answer
City
*
Your answer
State
*
Your answer
Zip Code
*
Your answer
Do you live in Durango city limits?
*
Yes
No
Is the participant their own legal guardian?
*
If the answer is NO, your legal guardian or legal representative must sign our waiver & release of liability agreement on your behalf.
Yes
No
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