Kayak Clinic Application

Kayak Clinic Application
Please complete this application if you are interested in joining the Sports Association for one of our Adaptive Kayak Clinics. Kayak Clinics are offered four times per year, typically in March, April, June and November. Clinics are located in the pool at Gaylord Hospital in Wallingford, CT. If you are a new participant with the Gaylord Sports Association, a member profile must also be completed. All participants must also read and sign our liability waiver and media release (optional) annually.

*Please note that all essentially eligibility criteria must be met prior to participation. A list of essential eligibility is included in this form.*

Please call us at 203-284-2772 or email us at sports@gaylord.org with any questions.
I would like to register for a Gaylord Sports Association Kayak Clinic.*

YesNo
I am interested in the following class.*

Friday, November 7, 1:00-4:00 PM
Participant Information
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
E-mail*
example@example.com
Date of Birth*

MonthDayYear
Are you a Veteran?*

YesNo
What is your gender?*

MaleFemalePrefer not to answer
How would you best describe yourself?*

WhiteAsian (Origin: example Chinese; Indian; Afghan; Filipino; Iranian; etc.)Black/African AmericanAmerican Indian or Alaska NativeNative Hawaiian or other Pacific IslanderPrefer not to answerOther
Are you of Hispanic/Latino/Spanish origin?*

No, not of Hispanic, Latino, or Spanish originYes, I am of Hispanic, Latino, or Spanish (Origin: example Mexican, Puerto Rican, Cuban, Dominican, Colombian, Spaniard, Ecuadorian, etc.)
Sports Association Membership
Have you participated in a Gaylord Sports Association Program in the past?*

YesNo
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 Kayak Application form.
Kayak Information
Do you have prior kayaking experience?*

YesNo
If yes, please describe
When was the last time you were in the water or pool?*
What are your goals for your participation in this program? *
Will you require assistance to transfer into a kayak that is on floor level?*

YesNo
Please describe any modifications you think you may need for kayaking (if knows).
Essential Eligibility
In order to participate in the kayak clinic, each participant must acknowledge the following essential eligibility criteria. The criteria below is established by the American Canoe Association as well as the Gaylord pool infection control policy.
Please acknowledge that you meet the criteria below by clicking on each box. If you do not meet all of the criteria below, please explain in the comment box at the end of this form.*

Have a significant mobility impairment or visual impairment that limits the ability to participate in recreation activities.Breathe independently (i.e., not require medical devices to sustain breathing)Independently maintain sealed airway passages while under waterIndependently hold head upright without neck / head supportBe able to manage personal care independently or with the assistance of a companion who accompanies you to the event. Please note SA staff does not provide personal care for participants.Manage personal mobility independently or with a reasonable amount of assistanceFollow instructions and effectively communicate independently or with assistance of a companionAble to wear life jacketNo open sores, skin breakdown or skin infectionsBe continent of bowel and bladder, no diarrhea in past 24 hoursNo acute feverNo peripheral or central catheters(a healed non-accessed implanted port is allowed)No seizures in the past 3 months
The following essential eligibility criteria will be taught and practiced during the kayak class. Please acknowledge that you will be able to practice the criteria below:*

While in the water, independently turn from face-down to face-up and remain floating face up while wearing a properly fitted life jacketGet in/out of the kayak independently or with a reasonable amount of assistanceIndependently get out and from under a capsized kayakRe-enter the kayak following deep water capsize independently or with a reasonable amount of assistanceMaintain a safe body position while attempting skills, activities and rescues and have the ability to recognize and identify to others when such efforts would be unsafe given your personal situation
Please tell us about any concerns, questions or comments about the above above essential eligibility criteria:
Medical Information
What is your primary diagnosis?*

Spinal Cord InjuryTraumatic Brain InjuryMultiple SclerosisStrokeAcquired Brain InjuryAmputeePTSDSpina BifidaVisual ImpairmentOther
Secondary Diagnosis (if applicable)
Do you have a history of seizures? (If yes, a seizure action plan may be requested).*

YesNo
What is the date of your last seizure and what type of seizure did you have?
Has your medical history changed since the last time you attended a Sports Association program?*

YesNoNot Applicable
If yes, please indicate the nature of these changes.
I am able to obtain a Doctor's note for medical clearance to participate if required.*

YesNo
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.
Should be Empty:

Kayak Clinic Application

Participant Information

Sports Association Membership

Kayak Information

Essential Eligibility

Medical Information

Acknowledgment