Athlete’s Personal Information
First Name *
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Last Name *
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Street Address *
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Town/City *
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Postal Code *
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Home Telephone *
If you don't have a landline, please type "none"
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Cell *
If you don't have a cell number, please type "none"
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Athlete's Date of Birth *
Please enter in this format: January 2, 1999
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Male/Female *
School *
If you are no longer in school, please type "none"
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Grade *
If you are no longer in school, please type "none"
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Athlete's Diagnosis
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Strengths and interests
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Challenges (communication, feeding, learning, mobility, social, energy, behaviour, etc.)
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Toileting Abilities
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Athlete Learns Best by ...
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Goals for participation with HOC
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Equipment / Assistive Devices (braces/orthotics, communication devices, insulin pump, wheelchair, walking aids, etc.)
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Athlete Requires Assistance With ...
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Additional Notes
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