Adaptive Climbing Clinic Registration

Adaptive Climbing Clinic Registration

Saturday, April 12, 2025 Central Rock Gym, Glastonbury, CT.
This form is to register as a participant or volunteer at the Gaylord Sports Association Adaptive Climbing Clinic on Saturday, April 12, 2025 at Central Rock Gym, Glastonbury, CT. We will be offering this year's clinic from 2:00 pm - 5:00 pm.

Please complete this form to register. At the end of the form, you will be directed to the link to sign our liability waiver and media release. Once this form is completed and waiver submitted, we will confirm your registration with a phone call or email.

There is no clost to attend this clinic.

This clinic is currenlty full. Please complete the form to be placed on a waiting list as we may be able to open additional spots. We are also currently recruiting additional volunteers with belay experience.

The Sports Association offers adaptive sports and recreation to individuals with a permanent disability or visual impairment, 16 years old and above.

Please contact us at 203-284-2772 or sports@gaylord.org with any questions.

Looking forward to seeing you soon!
Registration Information
I would like to register for the Adaptive Climbing Clinic on April 12, 2025 from 2:00 pm to 5:00 pm at Central Rock Gym in Glastonbury:*

Yes
Please select your registration type:*

Adaptive ClimberVolunteerGuest/Family Member/Support Person
Please select your volunteer role preference. Please note that volunteers will be scheduled for 1:00 pm - 5:00 pm.*

I am belay certified and would like to be paired with an adaptive climber during the clinic (to provide belaying and coaching with oversight from adaptive climbing instructors).I am an experienced adaptive climbing facilitator and willing to be an adaptive team leader.I would like to volunteer in a non-climbing role (such as registration, equipment assistance, photos/video, set-up/clean-up, etc.).Other
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
What is your gender?*

MaleFemaleI prefer not to answer
Are you a Veteran?*

YesNo
Please select your current military status:*

VeteranActive Military DutyReserve
What is your service branch?*
Please select your military service:*
Do you have a military disability classification?*

YesNo
If yes, what % disabled?
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.)
Please select:*

I am over the age of 18 and can legally sign for myself.I am either under the age of 18, legally conserved or not my own guardian.
Name of Legal Guardian or Conservator

First NameLast Name
Phone Number of Legal Guardian
Please enter a valid phone number.
Relationship to Legal Guardian
Emergency Contact *

First NameLast Name
Phone Number*
Please enter a valid phone number.
Relationship to Participant*
Sports Association Membership
Have you participated in a Gaylord Sports Association Program in the past?*

YesNo
Are you interested in learning more about Sports Association programs?*

YesNo
Climbing Information
Please describe your climbing experience (select all that apply):*

First Time!I have participated in one or more clinicsI climbed pre-injuryI currently climb on a regular basisExpert climberOther
I anticipate climbing as a:*

Sit ClimberStand Up ClimberUnsure
Please tell us about any specific climbing equipment, modifications you may need or any other comments regarding your adaptive needs (if known):
Are you belay certified at Central Rock Gym Glastonbury?*

YesNoUnsure
Briefly describe your experience facilitating adaptive climbing - if any.*
Do you have any dietary restrictions? (no dairy, gluten free, vegetarian)
Medical Information
What is your primary diagnosis?*

Spinal Cord InjuryTraumatic Brain InjuryMultiple SclerosisStrokeAcquired Brain InjuryAmputeePTSDSpina BifidaVisual ImpairmentI do not have a disabilityCOPDOther
Secondary Diagnosis (if applicable)
Please describe your mobility status:*

IndependentAmbulate with device (cane or walker)Use Manual WheelchairUse Power WheelchairOther
Please indicate if you have any of the below conditions?*

AllergiesAsthmaDiabetesCardiac ConditionHearing ImpairmentSeizures/History of seizuresDifficulty breathingHospitalization(s) within the past yearChronic PainMobility Impairment (please describe in the comment box below).Cognitive Impairments (learning new things, following directions, memory)Difficulty with communication, making my needs known or people understanding meMental Health condition (readjustment issues, anxiety, depression)Behavioral or emotional difficulties (impulsive, easily frustrated)I have none of the above conditionsOther
If any of the above apply, please provide additional information here. Or, please make any additional comments about your disability or medical history that we should be aware of:
How did you hear about this program?

Email from the Sports AssociationGaylord Employee/Gaylord TherapyInternet SearchOther
Do you have any questions or additional information you would like to share?
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.
Today's Date*

MonthDayYear
Date
Name of person completing form:*

First NameLast Name
Signature*

Clear
Liability & Media Waiver
All participants, volunteers, and coaches must sign an annual liability waiver and optional media release. Once this form is submitted, please follow the instructions provided to sign the online waiver.
Should be Empty:

Adaptive Climbing Clinic Registration

Registration Information

Participant Information

Sports Association Membership

Climbing Information

Medical Information

Acknowledgment

Liability & Media Waiver