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.*

  • Participant Information

  • Format: (000) 000-0000.
  • Date of Birth*
     - -
  • Are you a Veteran?*
  • What is your gender?*
  • How would you best describe yourself?*
  • Are you of Hispanic/Latino/Spanish origin?*

  • 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 Kayak Application form. 

  • Kayak Information

  • Do you have prior kayaking experience?*
  • Will you require assistance to transfer into a kayak that is on floor level?*

  • 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.*
  • 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:*

  • Medical Information

  • What is your primary diagnosis?*
  • Do you have a history of seizures? (If yes, a seizure action plan may be requested).*
  • Has your medical history changed since the last time you attended a Sports Association program?*
  • I am able to obtain a Doctor's note for medical clearance to participate if required.*

  • 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. 

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