TRAS Participant Skier Information Form 2022

Name *

First Name Last Name

Age *

Date of Birth *

Address *

Street Address

Street Address Line 2

City State

Zip Code

Home Phone *

Please enter a valid phone number.

Cell Phone *

Please enter a valid phone number.

WorkPhone

Please enter a valid phone number.

Email *

example@example.com

Height & Weight *

Primary Disability & Date of Onset *

If SCI Please note Level of Injury

Skiers w/ Spinal Cord Injuries less than one year since injury are required to provide a written physician clearance letter prior to skiing with the Three Rivers Adaptive Sports ski program

Secondary Disability if applicable

Do you have any type of spinal stabilization and/or rods? *

Yes No

If Yes, type of stabilization, rod length.

Do you wear braces or AFO's? *

Yes No

If so, what type?

Do you use any other assistive devices? If so, what type?

What is your primary means of mobility? *

Walking UNASSISTED Cane Crutches Walker Manual Wheelchair Power Wheelchair Scooter Other

Do you have movement or joint limitations? Please specify. *

Do you have problems with skin integrity? If so, what is the location? *

Do you have any skin breakdown currently? If so, what is the location? *

Do you have decreased sensation / ability to feel Pain, Cold, or Pressure? If so, what is the location? *

Do you need assistance for transfers? *

Yes No

Do you need assistance to get up from the floor? *

Yes No

Do you have any allergies [food, medications, etc]? *

Do you have a history of seizures? If yes, please explain. Include type, frequency, date of last seizure. Do you know when you are going to have a seizure?

Do you have any of the following conditions? *

Asthma Diabetes High Blood Pressure Low Blood Pressure Hepatitis Autonomic Dysreflexia HIV/AIDS Bladder Drainage Device None

Do you wear glasses? *

Yes No

Do you wear contacts? *

Yes No

Do you have sensitivity to sun and/or cold? If yes, specify. *

Have you had any surgeries in the past? If yes, specify. *

Are you currently under a doctor's care? If yes, specify. *

Do you need to limit your activities for any reason? If yes, specify. *

List all medications you are taking including dose, reason, and side effects. *

List EMERGENCY CONTACTS including phone number and relationship. *

Have you ever skied before? If yes, specify. Beginner, Intermediate, or Advanced? *

Skiing Methods

TWO SKI. Include with or without poles, shoe / boot size, ski length.

FOUR TRACK. Two skis with outriggers, other devices such as bra/ski tip stabilizer, spreader bar, tether, etc, shoe/boot size, length of ski.

MONO SKI. Model used if known, tethered?

Do you need assistance getting on/off lift? If yes, what type? *

Do you need assistance getting up from the ground? *

BI SKI. Model used if known, hand held outriggers, fixed outriggers, tethered?

Do you have your own equipment? *

Yes No

(Note: ALL sit down skiers MUST have a lift retention strap and emergency evacuation system attached to their sit down ski unit)

Please provide any/all additional information you feel your ski instructor should know about in order to make you skiing experience as safe and successful as possible: *

NOTE: ALL SKIERS/SNOWBOARDERS PARTICPATING IN THE THREE RIVERS ADAPTIVE SPORTS SKI PROGRAM ARE REQUIRED TO WEAR A HELMET

By signing below, I verify that the above information is current and accurate. I understand that the information above is confidential and will only be used by the instructor and volunteers to provide the student with a safe and enjoyable skiing experience.

Participant's Signature *

Clear

Parent/Guardian Name if Participant is a MINOR.

Parent/Guardian Signature

Clear

“If I can do this, I can do anything”

Three Rivers Adaptive Sports P.O. Box 38235 Pittsburgh, PA 15238 (412) 848-8896 www.traspa.org