2024 Participant Snow Ski Registration Update

2024 Participant Snow Ski Registration Update
Participant Type*
Participant Sub-type*
Branch of Service*
Rank
Last Name*
First Name*
Birth Date*

MonthDayYear
Date
Disability Type*
Disability Sub-Type*
Date of Injury

MonthDayYear
Date
Place of Injury
Gender*
LGBTQ*
Race*
Hispanic, Latino or Spanish Origin*
Address*
City*
State*
Zip*
Cell Phone*
Home Phone*
E-mail*
Skiers w/ Spinal Cord Injuries less than one year since injury are required to provide a written physician clearance letter prior to skiing with the Three Rivers Adaptive Sports ski program
Height & Weight*
Secondary Disability if applicable
Do you have any type of spinal stabilization and/or rods?*

YesNo
If Yes, type of stabilization, rod length.
Do you wear braces or AFO's?*

YesNo
If so, what type?
Do you use any other assistive devices? If so, what type?
What is your primary means of mobility?*

Walking UnassistedCaneCrutchesWalkerManual WheelchairPower WheelchairScooterOther
Do you have movement or joint limitations? Please specify.*
Do you have problems with skin integrity? If so, what is the location?*
Do you have any skin breakdown currently? If so, what is the location?*
Do you have decreased sensation / ability to feel Pain, Cold, or Pressure? If so, what is the location?*
Do you need assistance for transfers?*

YesNo
Do you need assistance to get up from the floor?*

YesNo
Do you have any allergies [food, medications, etc]?*
Do you have a history of seizures? If yes, please explain. Include type, frequency, date of last seizure. Do you know when you are going to have a seizure?
Do you have any of the following conditions?*

AsthmaDiabetesHigh Blood PressureLow Blood PressureHepatitisAutonomic DysreflexiaHIV/AIDSBladder Drainage DeviceNone
Do you wear glasses?*

YesNo
Do you wear contacts?*

YesNo
Do you have sensitivity to sun and/or cold? If yes, specify.*
Have you had any surgeries in the past? If yes, specify.*
Are you currently under a doctor's care? If yes, specify.*
Do you need to limit your activities for any reason? If yes, specify.*
List all medications you are taking including dose, reason, and side effects.*
List EMERGENCY CONTACTS including phone number and relationship.*
Have you ever skied before? If yes, specify. Beginner, Intermediate, or Advanced?*
Skiing Methods
TWO SKI. Include with or without poles, shoe / boot size, ski length.
FOUR TRACK. Two skis with outriggers, other devices such as bra/ski tip stabilizer, spreader bar, tether, etc, shoe/boot size, length of ski.
MONO SKI. Model used if known, tethered?
Do you need assistance getting on/off lift? If yes, what type?*
Do you need assistance getting up from the ground?*
Do you have your own equipment?*
(Note: ALL sit down skiers MUST have a lift retention strap and emergency evacuation system attached to their sit down ski unit)
Please provide any/all additional information you feel your ski instructor should know about in order to make your skiing experience as safe and successful as possible: *
NOTE: ALL SKIERS/SNOWBOARDERS PARTICPATING IN THE THREE RIVERS ADAPTIVE SPORTS SKI PROGRAM ARE REQUIRED TO WEAR A HELMET

By signing below, I verify that the above information is current and accurate. I understand that the information above is confidential and will only be used by the instructor and volunteers to provide the student with a safe and enjoyable skiing experience.
Participant's Signature*

Clear
Parent/Guardian Name if Participant is a MINOR.
Parent/Guardian Signature

Clear
Clicking the 'Submit' button will take you to the Liability Release Form.
Should be Empty: