Event Registration Form

Event Registration Form

Please complete the form below to register for a Gaylord Sports Association Event. To contact us, call 203-284-2772 or email sports@gaylord.org. For more information on our programs, please visit www.gaylord.org/sports.
General Information
Name of event you would like to register for:
I would like to register for:

Other Event - Please Type Name and Date
Date of Event

MonthDayYear
Type of Registration:

Other
If Guest, please indicate relationship
If you are registering as part of a group, or member of an organization, please indicate the name here:
General Information
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Format: (000) 000-0000.
E-mail
example@example.com
Date of Birth

MonthDayYear
What is your gender?
Are you a Veteran?
Please select your current military status:
What is your service branch?
Please select your military service:
Do you have a military disability classification?
If yes, what % disabled?
How would you best describe yourself?
Are you of Hispanic/Latino/Spanish origin?
T-Shirt Size
Please select:
Name of Legal Guardian or Conservator

First NameLast Name
Phone Number of Legal Guardian
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Participant
Emergency Contact

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship of Emergency Contact
Sports Association Membership
Have you participated in a Gaylord Sports Association Program in the past?
If you are not a member of the Sports Association, or have not participated in a program in the last 3 years, please complete a member profile as part of your registration. Click here to complete profile. Following completion, return and complete this event form.
Are you interested in learning more about Gaylord Sports Association programs?
I am
Medical Information
What is your primary diagnosis? (If none, choose "I do not have a disability" below).

Other
Secondary Diagnosis (if applicable)
Date of initial onset of primary diagnosis
Please indicate if you have any of the below conditions?

Other
If any of the above apply, please provide additional information here. Or, please make any additional comments about your disability or medical history that we should be aware of:
Do you use an assistive mobility device?
If yes above, please tell us more about your mobility:
Will you be using a wheelchair while participating in a Sports Association program?
How did you hear about this program?

Other
Do you have any questions or additional information you would like to share?
Acknowledgment
By submitting this form, 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.
Today's Date

MonthDayYear
Name of person completing form:

First NameLast Name
If not self, please indicate relationship to participant (friend, guardian, therapist, etc.)
Signature
Liability & Media Waiver
All attendees including 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.
Should be Empty:

Event Registration Form

General Information

General Information

Sports Association Membership

Medical Information

Acknowledgment

Liability & Media Waiver