Adaptive Lesson Inquiry
Email Address *
First and Last Name of Participant *
Date of Birth *
MM
/
DD
/
YYYY
Your Name (if different)
Phone Number *
Street Address *
City *
State *
Zip Code
Discipline *
Lesson Date *
MM
/
DD
/
YYYY
Height
Weight
Shoe Size
Participant Disability/Diagnosis *
Other related medical information and/or recent surgeries that may impact snow sports participation
Medications (and any relevant side effects)
Previous Snowsports or Other Recreational Activity
Skiing/Riding Goals
Instructor Request
If requested instructor is unavailable, are you okay with a different instructor?
Best time to contact you?
Other Comments
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