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27
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1
Name
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First Name
Last Name
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2
Email
*
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example@example.com
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3
Date of Birth
*
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Date
Day
Month
Year
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4
Gender
*
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Female
Male
Female
Male
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5
Country of Origin
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6
Phone Number
Area Code
Phone Number
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7
Instagram
ex: @wheelwod
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8
Instagram
ex: @wheelwod
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9
Have you ever competed in competitive CrossFit or similar fitness competitions?
*
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YES
NO
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10
Have you ever competed in competitive sports as an adaptive athlete?
*
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YES
NO
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11
Which category best describes your perceived classification?
*
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Upper 1 Point of Contact
Upper 2 Point of Contact
Seated with Hip Function
Seated without Hip Function
Neuro Major
Neuro Minor
Visual and Hearing
Short Stature
Lower Above Knee Impairment
Lower Below Knee Impairment
Intellectual Disabilities
Other
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12
Please describe in detail your impairment.
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13
Please select one of the below.
*
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I agree to uploading medical documentation to WheelWod and their subsidiaries for review of the sole purpose of classification in competitive fitness provided by WheelWod, Inc.
I will not be uploading medical documents at this time/ do not have access.
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14
Please upload supporting medical documentation.
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15
Does your impairment affect your ability to function through the following: STRENGTH
*
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Please rate 0-5, zero meaning no affect five meaning completely impaired. If the impairment has no effect please answer Not Applicable.
Pressing
Pushing
Pulling
Hinging
Squatting
Balance & Coordination
Moving from Floor to Stand or Floor to Seated
Rotation
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16
If you answered yes to any of the previous functions please describe how. Please be specific.
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17
Please describe any scaling/modifications or adaptations used as it pertains to the above functions.
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18
Does your impairment affect your ability to function through the following: SPEED
*
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Please answer yes or no for each of the following movements. If the impairment has no effect please answer Not Applicable.
Pressing
Pushing
Pulling
Hinging
Squatting
Balance & Coordination
Moving from Floor to Stand or Floor to Seated
Rotation
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19
If you answered yes to any of the previous functions please describe how. Please be specific.
*
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20
Please describe any scaling/modifications or adaptations used as it pertains to the above functions.
*
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21
Does your impairment affect your ability to function through the following: BALANCE
*
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Please answer yes or no for each of the following movements. If the impairment has no effect please answer Not Applicable.
Pressing
Pushing
Pulling
Hinging
Squatting
Balance & Coordination
Moving from Floor to Stand or Floor to Seated
Rotation
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22
If you answered yes to any of the previous functions please describe how. Please be specific.
*
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23
Please describe any scaling/modifications or adaptations used as it pertains to the above functions.
*
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24
Does your impairment affect your ability to function through the following: FLEXIBILITY/ RANGE OF MOTION
*
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Please answer yes or no if you have a limited range of motion in the following joints. If yes, please explain on the next question. If the impairment has no effect please answer Not Applicable.
Wrist
Elbow
Shoulder
Hips
Knee
Ankle
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25
Please explain limitations in range of motion from prior question.
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26
Please describe any scaling/modifications or adaptations used as it pertains to the above functions.
*
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27
Please include any additional information you would like to provide.
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28
Please verify that you are human
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29
Tags
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