Adaptive Program - Participant Information Sheet

Adaptive Program - Participant Information Sheet

Please fill out this application completely and accurately. To book a reservation please call: 575.776.2291 ext. 2355
Name

First NameLast Name
Date(s) of Lesson

MonthDayYear
Date
Age
Date of Birth

MonthDayYear
Date
Gender
Height
Weight
Address, City, State & Zip Code
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Diagnosis-Primary
Secondary
Details
YesNo
Primary language spoken/understood
YesNo
If yes, when?
If yes, what type of seizure?
YesNo
What is the primary means of mobility (i.e. power wheelchair, manual wheelchaire, can, walker, etc.)
Parent/Guardian/Caregiver Information
Name

First NameLast Name
Relation
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Emergency Contact Information

(If different from Parent/Guardian/Caregiver)
Name

First NameLast Name
Relation
Address
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
General Information
What are your favorite activites or topics?
What are your dislikes?
Family Do's and Don't's:
Anything else we should know?
Participant Medical History
Today's Date

MonthDayYear
Date
Thank you for your interest in participating in programs with Taos Ski Valley. In order to safely provide this service, Taos Ski Valley requests that you complete/update the following medical forms. Please note that the following conditions may suggest precautions and contraindications to participation in some programs. Therefore, when completing this form, please check whether these conditions are present and to what degree.
Atlanto Axial Instability - include neurologix symptomsCoxarthorosisCranial DefectsHeterotopic Ossification/Myositis OssificansJoint subluxation/dislocationOsteoporosisPathologic FracturesSpinal Joint FusionSpinal Joint Instability/Anbormalities
Hydrocephalus/ShuntSeizureSpina Bifida/Chiari II Malformation/ThetheredCord/Hydromyelia
AllergiesAnimal AbuseCardiac ConditionPhysical/Sexual AbuseEmotional AbuseBlood Pressure ControlDanergous to Self or OthersFire SettingHemophiliaMedical InstabilityMigrainesPVDRespiratory CompromiseRecent SurgeriesSubstance AbuseThoughts Control DisordersWeight Control Disorder
Age - under 4 years oldIndwelling Catheters/Medical EquipmentMedications - i.e. PhotosensitivityPoor EnduranceSkin Breakdown
Physical Concerns
No concerns (if no concerns, skip ahead)
Sits unassistedStands unassistedWalks unassistedRuns unassistedUses hands independentlyReleases objectsBears weight on handsClimbs stairsBears weight on legsShunt/Catheters
Describe general balance
Concerns with temperature
Concerns with pressure sores or skin breakdown
Concerns with muscle spams/tightness
Concerns with speech
Hand/eye coordination
YesNo
YesNo
No AssistPartial AssistTotal Assist
Dietary Restrictions: Please list and food restriction
Allergies: Please list ALL known allergies (foods, environmental, medications, animals, etc.)
Program Specific
YesNo
YesNo
YesNo
YesNo
YesNo
Have you skied or snowboarded before? If yes, when? Where? What is your skill level?
SkisPolesSnowboardMono SkiBi SkiSnow SliderBoard BuddySki PalRider BarTip ClampsTethersOther
Personal Care/Independence

Taos Ski Valley does not provide personal care. If you or the participant needs assistance in the below areas, you will need to provide an aide/caretaker. Please select the most appropriate answer for the categories below:
IndependentPartial AssistTotal Assist
NormalOccasional Incontinence
NormalOccasional Incontinence
IndependentPartial AssistTotal Assist
IndependentPartial AssistTotal Assist
YesNo
Sensory Concerns
No Concerns (if there are no concerns, skip ahead)
Partially sighted/legally blindTotally blind
Please describe the amount of vision the participant has:
Partial hearing lossTotal hearing loss
Please describe how hes/she best communicates:
Please describe sensitivities in the following areas:
Visual (seeing):
Auditory (hearing):
Olfactory (smelling):
Tactile (touching):
Proprioceptive (movement):
What sensory situations upset him/her?
Assistive technology used:
Cognition and Processing
No Concerns (if no concerns, skip ahead)
Knows numbersKnows lettersKnows left/rightKnows prepositionsCommunicates feelingsMakes choicesSees colors
Recognizes nameMakes eye contactWaves: says hi/byeShares toys/itemsKnows safety awarenessInteracts with peersHas appropriate conversationsTakes turnsUnderstands personal space
Makes soundsSays wordsCombines 2 or more wordsSpeaks in complete sentencesUnderstands "no"Signs or uses gesturesUses picture symbols
1 Step2 Steps3 StepsComplex
Visual/learns by seeingAuditory/learns by hearingKinesthetic/learns by doing
PoorFairAverage
PoorFairAverage
Should be Empty:

Adaptive Program - Participant Information Sheet

Parent/Guardian/Caregiver Information

Emergency Contact Information

General Information

Participant Medical History

Physical Concerns

Program Specific

Personal Care/Independence

Sensory Concerns

Cognition and Processing