Adaptive Climbing Clinic Registration

Adaptive Climbing Clinic Registration

Saturday, April 11, 2026 Central Rock Gym, Glastonbury, CT.
This progam is currently FULL for participants and volunteers - Please continue to complete this form to be added to the waiting list. Thank you!

This form is to register as a participant or volunteer at the Gaylord Sports Association Adaptive Climbing Clinic on Saturday, April 11, 2026 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.

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 11, 2026 from 2:00 pm to 5:00 pm at Central Rock Gym in Glastonbury:
Please select your registration type:
Please select your volunteer role preference. Please note that volunteers will be scheduled for 1:00 pm - 5:00 pm.

Other
Participant Information
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Format: (000) 000-0000.
E-mail
example@example.com
Date of Birth

MonthDayYear
What is your gender?
Are you a Veteran?
Please select your current military status:
What is your service branch?
Please select your military service:
Do you have a military disability classification?
If yes, what % disabled?
How would you best describe yourself?
Are you of Hispanic/Latino/Spanish origin?
Please select:
Name of Legal Guardian or Conservator

First NameLast Name
Phone Number of Legal Guardian
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Legal Guardian
Emergency Contact

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Participant
Sports Association Membership
Have you participated in a Gaylord Sports Association Program in the past?
Are you interested in learning more about Sports Association programs?
Climbing Information
Please describe your climbing experience (select all that apply):

Other
I anticipate climbing as a:
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?
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?

Other
Secondary Diagnosis (if applicable)
Please describe your mobility status:

Other
Please indicate if you have any of the below conditions?

Other
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?

Other
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
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