Trailblazers Adventure Group
Thank you for sharing information about yourself so that we can plan some amazing adventures! One of our staff will contact you to discuss our upcoming group!
Personal Information
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Medical/Neuro diagnosis
Mobility & Equipment
Type of wheelchair (select all that apply)
Manual
Power/Electric
Transport chair
Powered Scooter
Other
Do you use any additional mobility aids?
Cane
Walker
Braces
Hiking poles
Other
Transfer Level & Assistance Needs
Do you have any specific assistance needs with transfers, walking, etc?
Medical Conditions
Is there anything you are concerned about for participation?
Do you have any allergies we should be aware of? (bees, poison oak...)
Mobility Distance & Terrain
What is your approximate comfortable wheeling or walking distance on a paved surface?
Under 1 mile
1-2 miles
2-5 miles
Unsure
What is your approximate comfortable wheeling or walking distance on a trail surface (uneven ground)?
Under 1 mile
1-2 miles
2-5 miles
Unsure
What surfaces can you navigate for short distances (500 ft)?
Paved paths
Packed gravel
Grass/uneven terrain
Rough/rocky terrain
Unsure
Can you navigate inclines or hills independently?
Yes
No
With assistance
Unsure
Do you do any walking or ambulation?
No
Household distances only
Community distances with mobility device
Other
Do you have transportation to get to locations throughout Central Oregon?
Yes
No
Sometimes
Upper Body Function
Rate your overall shoulder/arm mobility
No movement
1
2
3
4
Full range
5
1 is No movement, 5 is Full range
Rate your overall shoulder/arm strength
No strength
1
2
3
4
Very strong
5
1 is No strength, 5 is Very strong
Final Comments
What are your goals or hopes for this group?
Any other helpful information for our team?
Submit
Should be Empty: