Gaylord Sports Association Member Profile

  • Sports Association Member Profile

  • Welcome to the Gaylord Sports Association!

    The Gaylord Sports Association is a program of Gaylord Specialty Healthcare, based in Wallingford, CT.  We have been dedicated to helping people with a physical disability or visual impairment to experience the benefits of sports and recreation for over 20 years!  By completing this member profile form, you will be joining the program and sharing information about yourself so that we can learn about you and how we can help you reach your adaptive sports goals! If you haven't already met with us, we'll contact you after we recieve this form with the next steps on how to get started! 

    If you have any questions, we can be reached at 203-284-2772 or sports@gaylord.org.  Additional information about the Gaylord Sports Association can be found on our webpage at www.gaylord.org/sports.

    -The Sports Association Team

    Katie Joly, Sports Association Program Manager

    Debbie Gibilaro, Adaptive Sports Program Specialist

    Tyler Rogers, Adaptive Sports Program Coordinator

    Danielle Orsini, Adaptive Sports Program Specialist

  • CONTACT INFORMATION

  • Format: (000) 000-0000.
  • Date of Birth*
     - -
  • Relationship to Participant*
  • Format: (000) 000-0000.
  • Please Select:*
  • Format: (000) 000-0000.
  • Are you a current or prior patient of Gaylord Specialty Healthcare?*
  • What type of patient have you been at Gaylord (select all that apply):
  • If you are currently receiving outpatient therapy at Gaylord, select location:
  • If you are a prior outpatient at Gaylord, select location:
  • Do you require an attendant to assist you with personal care?*
  • Do you plan to bring someone to assist you? (We are not able to provide assistance with personal care needs.)
  • Are you currently? (check all that apply)*
  • What is your gender?*
  • How would you best describe yourself?*
  • Are you of Hispanic/Latino/Spanish origin?*

  • MILITARY INFORMATION

  • Do you serve or have you served in the Military?*
  • Please select your current military status:*
  • Do you have a military disability classification?*
  • Are you currently receiving INPATIENT care at a medical facility?

  • BACKGROUND INFORMATION & INTERESTS

  • How did you hear about us?*
  • Have you participated in a Sports Association Event in the Past?*
  • Do you have a service dog? (no family pets please)*
  • Will your dog attend programs with you?
  • I am interested in these sports offered by the Sports Association (select all that apply):*
  • Other Sports of Interest (select all that apply):
  • I have participated in water based activities within the past year?*

  • MEDICAL INFORMATION

  • The Gaylord Sports Association serves individuals with a physical disability or visual impairment ages 16 and up. 

  • Please select your primary diagnosis:*
  • Date of Injury or Onset:*
     - -
  • Type of Spinal Cord Injury
  • Type of amputation:
  • Please mark any of the following that are true about you vision:
  • What type of CVA (stroke) did you have?
  • Please indicate if you have any of the following conditions:*
  • Do you have any allergies?*
  • Are you currently taking any medications (blood thinners, seizure medications, pain medications, etc.)?*
  • Do you smoke? (Please note that the Sports Association complies with Gaylord Specialty Healthcare's No Smoking Policy at all programs)*
  • Are you able to obtain a doctor's note for participation in adaptive sports?(A doctor's note may be required based on medical history or requirements for participation in a specific sport.)*

  • FUNCTIONAL ABILITIES

  • Please describe your ambulation status:*
  • What assistive device do you use? (select all that apply)?*
  • I am:
  • How would you describe your transfer status (moving yourself from one surface to another, such as into a vehicle or onto the floor)?*
  • Please indicate if you have any of the following physical conditions:*
  • Please indicate if any of the following apply to you:*
  • What type of behavioral or emotional difficulties do you experience? (select all that apply):
  • What type of communication difficulties do you have? (select all that apply):
  • What type of cognitive difficulties do you have? (select all that apply):

  • ACTIVITY LEVEL

  • Do you participate in any exercise program?*
  • How would you describe your endurance?*
  • Do you need to limit your activities for any reason?*

  • ACKNOWLEDGEMENT

  • By signing below, I verify that the above information is current and accurate. I understand that the above information will be kept confidential. In order to provide a safe and fun experience, your information may be shared with: (1) Sports Association staff, coaches or instructors, (2)other adaptive sports programs who will be working with you, (3)medical professionals in case of emergency, (4) as required for Sports Association grant reports. I understand that it is my responsibility to inform the Sports Association regarding changes to my:(1) contact information such as address, phone, and email: (2) medical status including new diagnosis, surgery or medical changes; (3) any other information that is relevant to the safety of myself or others regarding my participation in Sports Association programs.

  • Liability & Media Waiver

  • All participants, volunteers, and coaches must sign an annual liability waiver and optional media release. Once this form is submitted, please follow the instructions provided to sign the online waiver.

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