Y&C adaptive waterski application

Adaptive waterski application

Yorkshire & Central
Various dates & locations, please see below for choices. All info is on the website here.

Please complete this form so we have all the necessary information to make sure we can set you up with the most appropriate adaptive equipment/ teaching technique.

We subsidise costs for disabled skiers:

1 ski set = £25

2 ski sets = £35

3 ski sets = £40
Full name of participant*

First NameLast Name
Address (optional)

Street Address

Street Address Line 2

CityCounty

Postcode
Phone number*
Email*
example@example.com
D.O.B*

DayMonthYear
Date
Gender*

MaleFemale
Please list the date(s) you would like to apply for*

Sat 7 Sept (Treeton)Sat 21 Sept (Derby)
Please answer the questions below regarding your disability, so we can make sure we are able to support you safely
What is your primary disability?*
Is your disability acquired or congenital?*

AcquiredCongenital
Do you have a cognitive impairment? (this can mean when a person has trouble remembering, learning new things, concentrating, communicating, or making decisions that affect their everyday life)*

YesNo
Please provide further info on cognitive impairment
Balance*

1

2

3

4

5

1 is Worst, 5 is Best
Upper body strength*

1

2

3

4

5

1 is Worst, 5 is Best
Grip*

1

2

3

4

5

1 is Worst, 5 is Best
How easy is it to sit independently without support?*

1

2

3

4

5

1 is Worst, 5 is Best
Please list any medication you take regularly
Please tell us of anything else we should be aware of
Mobility*

WalkerWalker with aidManual wheelchair userPowerchair user
What type of skiing do you think you'd prefer?*

SeatedStandingNot sure
Weight (although there is not an official weight limit, we might contact you if we have concerns about available equipment or instructor abilities)*
Height*
Do you suffer from asthma?*

YesNo
Do you suffer from epilepsy?*

YesNo
Can you swim or float independently in deep water?*

YesNo
Name of parent of guardian (leave blank if this does not apply)

First NameLast Name
I hereby certify that the information given is correct to the best of my knowledge. Waterskiing and associated tow sports can be dangerous. By signing digitally below, I assume any risk of harm or injury which might occur to the participant due to participation in the event or activity. I release Access Adventures from all liability, costs and damages which might arise from participation in the activity.
Signature of participant or parent/ guardian*

Clear
Where did you hear about us?*
We would like to contact you with information about our services. This may include details on events, volunteering, fundraising. We won't share your information with others without your permission, except in an emergency. Your data will be used and stored in accordance with the 'General Data Protection Regulation 2018' Please refer to our website for our full privacy policy
Please DO contact me by (please mark ALL methods you would be happy with)*

EmailPhonePost
Should be Empty:

Adaptive waterski application