Inclusive Kayak Registrant Information (required)
Please complete this section for your Inclusive Kayak Registration.
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Email *
Name *
Address *
City *
State *
Zip Code *
Email *
Phone Number *
Date of Birth *
MM
/
DD
/
YYYY
Emergency Contact Name *
Emergency Contact Phone Number: *
Please list any disabilities you have (if any).
Please describe any limitations you experience (limited movements, difficulty following directions, unable to move left arm, etc): *
What is your weight ?   *
Do you have any allergies?  Please list below.
Do you walk independently? *
Please list an assistive devices you use for mobility (crutch, can, prosthetic leg, power chair, manual wheelchair, etc).
Do you have any sun precautions we should be aware of? *
Please indicate your level of experience in kayaking. *
Do you need to limit your physical activities for any reason? *
Do you have any special medical conditions the program staff should know about?  Please explain below.
Do you experience seizures? *
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