Adaptive Cycle Clinic Registration Form

Adaptive Cycle Clinic Registration

March 14, 2026 at Southern CT State University
Thank you for your interest in the Gaylord Sports Association Adaptive Cycle Clinic!

The Gaylord Sports Association is teaming up with local adaptive cycle providers and Southern CT State University for our annual Adaptive Cycle Clinic! This clinic is for individuals ages 16 and up with a physical disability or visual impairment to learn about various styles and models of adaptive bikes. There will be dozens of adaptive cycles to explore including foot-pedaled trikes, hand cycles and adaptive mountain bikes. Participants will have to opportunity to work with experts in the field and be fit to a cycle that works with their ability level. Test rides will be available on the indoor track.

Once this form is submitted, please click on the link to sign our annual liability and media waiver.
Registration:*

I would like to register for the Adaptive Cycle Clinic on March 14, 2026 at Southern Connecticut State University, New Haven, CT
Please select all session times you are available to attend. Final session assignments will be made prior to the clinic and confirmed in your confirmation email. Session times are scheduled based on cycle and vendor availability, and we appreciate your flexibility so we can provide the best possible experience for all participants.*

1 PM - 2 PM2 PM - 3 PM3 PM - 4 PMI am available for any of the session times
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
Emergency Contact*
Phone Number*
Please enter a valid phone number.
Relationship to Participant*
What is your gender?*

MaleFemaleI prefer not to answer
Are you a Veteran?*

YesNo
What is your service branch?*

ArmyNavyMarinesAir ForceCoast GuardNational GuardReserves
Please indicate if you served in any of the major conflicts below:*

KoreaVietnamGulfOEF/OIFN/A
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.)
What is your primary disability?*

AmputeeTraumatic Brain InjurySpina BifidaStrokeAcquired Brain InjuryMultiple SclerosisSpinal Cord InjuryVisual ImpairmentCOPDOther
Secondary Diagnosis (if applicable):
Please indicate if you have any of the following conditions. If yes, please provide details below:

ParalysisCardiac Condition (Coronary Heart Disease, Myocardial Infarction)Difficulty Breathing/COPD/Pulmonary Disease/AsthmaDiabetes (please indicate type below)History of SeizuresHearing Impairment / Hearing Loss / Use Hearing AidSkin Condition (wound, pressure ulcer, infection)Chronic PainPTSDRecent hospitalization or surgery
Please provide details on any of the above conditions or share any additional information about your disability that may be helpful for us:
Sports Association Membership
Have you participated in a Gaylord Sports Association Program in the past?*

YesNo
If you are not yet a member of the Gaylord Sports Association, or have not participated in a program in the last 3 years, please complete a member profile in addition to this cycle registration form. The member profile is an online form that is completed by all new members. Click here for the online form.
Cycle Information
Have you participated in a Sports Association Cycle Ride or Clinic in the past?*

YesNoUnsure
What are your goals for participation in this event? *
Please describe your prior cycling experience? (check all that apply)*

First time since injury/illnessHave ridden an adaptive cycle at least one or more timesRode prior to injuryBeginner cyclistExperienced cyclistOther
Please tell us about your equipment needs:*

I would like to find out which adaptive cycle works for meI am considering purchasing an adaptive cycle and would like more informationI have an adaptive cycleOther
What type of cycle would you like to try (if known)?*

HandcycleRecumbent (foot-powered) cycleTandem CycleAdaptive Mountain BikeUnsureOther
If there is a specific brand/model cycle you would like to try, please indicate it here:
Please describe any specific modifications you may need (if known):
What is your height? (For bike fitting purposes)*
What is your weight? (For bike fitting purposes)*
Please share any other information that will help us to provide you with the best experience at this event. If you would like to meet with a specific vendor (Bike-on, Ti-Trikes, Gaylord Sports Association), please indicate that here.
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.
Name of person completing this form:*
Signature*

Clear
Liability and 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 on the submission page to sign the online waiver.
Should be Empty:

Adaptive Cycle Clinic Registration

Participant Information

Sports Association Membership

Cycle Information

Acknowledgment

Liability and Media Waiver