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? *
If yes, what was/is your branch and rank?
Your answer
If you have down syndrome, have you had a neck x-ray?
If so, were there any abnormalities?
Your answer
If you have learning disabilities, what concepts are difficult?
Your answer
If you have a visual impairment, what is your field of vision?
Your answer
If you have a hearing impairment, what is the extent of hearing loss?
Your answer
If you have a spinal cord injury, what is your level of injury?
Your answer
What adaptive equipment do you use? *
Wheelchair, walker, etc.
Your answer
Are there any parts of your body susceptible to heat/cold?
Your answer
Are there any parts of your body susceptible to impact?
Your answer
Do you have seizures? *
Your answer
If yes to above, are seizures controlled?
Your answer
What was the date of your last seizure? *
Your answer
What medications do you take and what are they for? *
Your answer
Concerns or fears?
Your answer
Dietary concerns or allergies? *
Your answer
Recent injuries, illnesses, surgeries (in last year)? *
List dates and specifics
Your answer
Sports, activities and exercises
If so, how often?
Your answer
Is it okay with your doctor to participate in outdoor activities? *
What outdoor activities would you like to participate in?
To help with our funding, please check all that apply to you. *
Required
How did you first hear about ASA? *
Your answer
Additional comments?
Your answer
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