Adaptive Sports Association Participant Intake Form
Summer 2018
Are you a new or returning participant to ASA? *
Contact Information
First Name *
Your answer
Last Name *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Gender *
If Minor, Parent/Guardian's Name
Your answer
Are you (as the participant) your 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.
Guardian's full name
Your answer
Relationship to participant
Your answer
Participant's 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
E-mail *
Your answer
Emergency contact name *
Your answer
Emergency contact phone number *
XXX-XXX-XXXX
Your answer
Emergency contact relationship *
Your answer
Disability Information
Disability *
Your answer
Cause if known *
N/A if not
Your answer
When incurred *
Your answer
Height
Your answer
Weight
lbs.
Your answer
Are you a veteran or active duty service member? *
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