Clone of Athlete Registration Form - Summit Adaptive Sports

Welcome to Summit Adaptive Sports!

Participating in sports provides lifelong opportunities for physical and mental development as well as opportunities for individual accomplishment and inclusive family activities. Summit Adaptive Sports provides access and instruction in outdoor sports to individuals with developmental or acquired disabilities.

For more information on our organization, programs, and frequently asked questions please visit our website at summitadaptive.org. If you still have questions, please email us at summitadapt@summitadaptive.org.

Steps to Register:

Step 1: Complete the questionnaire below so that we can learn more about you (or your family member) and your interests so that we may best plan your lesson(s) experience.

Step 2: Once we receive your completed questionnaire you will receive a confirmation /thank you page with links to our waivers to be signed electronically. Please allow 3 business days for us to process your registration.

Please Note: If you are skiing or snowboarding during the winter you will need to contact the Summit Adaptive office directly at (860)379-7669 ext. 221. Summit will start booking lesson reservations on November 17th. This year Ski Sundown has a new system and all participants will create their own account. Once your lesson(s) time is approved, Summit will provide a link to you to make the payment for lessons online. Filling out this registration alone does not secure your lesson or program reservation.
- Participant Full Name
  
  First NameMiddle NameLast Name
- Please select:
- Parent or Guardian Full Name (If unable to sign for self):
  
  First NameLast Name
- Gender
  
  Other
- Preferred Pronouns
  (e.g. She/Her/Hers)
- Current Age
- Date of Birth
  
  MonthDayYear
- Current Address
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- E-mail
  example@example.com
- Mobile Number
  Mobile Phone Number Format: (000) 000-0000.
- Emergency Contact
  
  First NameLast Name
- Emergency Phone Number
  Emergency Phone Number Format: (000) 000-0000.
- Emergency Contact Relationship
- Are you coming with a specific group?
  For example: ASD- American School for the Deaf, BESB - Bureau of Education and Services for the Blind, etc..
- Do you serve, or have you served, in the Military?
- Height (ex. 5'0"):
- Weight (lbs):
- Shoe Size:
- Shoe Type
- We currently offer Alpine Skiing and Snowboarding during the winter season, and hope to offer Nordic (X-Country & Telemark) skiing depending on snow conditions. We also offer warm weather sports inclduing Kayaking, Hiking, Disc Golf, Skateboarding and Climbing/Adventure Course and various types of biking including Mountain Biking, Gravel Riding and Rails-2-Trails riding. Please let us know all the activities that you or your family member are interested in participating with Summit Adaptive Sports.
- 1. Alpine Skiing
- What is the level of ski experience?
- Please provide any detail available on prior skiing experience. If you have an acquired disability did you ski prior to injury or onset?
- Do you need Ski Rentals from Ski Sundown ?
- 2. Nordic Skiing
- Are you interested in:
- What is the level of cross country and / or telemark experience?
- Please provide any detail available on cross country and / or telemark experience. If you have an acquired disability did you cross country or telemark ski prior to injury or onset?
- Do you need cross country and/or telemark rental equipment?
- 3. Hiking
- What is the level of hiking experience?
- Please provide any detail available on hiking experiences. If you have an acquired disability did you hike before injury or onset?
- 4. Mountain Biking/Gravel Riding/Rails-2-Trails biking
- What is the level of mountain biking/gravel riding/ rails-2-trails biking experience?
- Please provide any detail available on mountain biking/trail riding experience. If you have an acquired disability did you mountain bike or trail ride prior to injury or onset?
- Do you need bike rental equipment?
- 5. Snowboarding
- What is the level of snowboarding experience?
- Please provide any detail available on snowboarding experience. If you have an acquired disability did you snowboard before injury or onset?
- Do you need Snowboard rentals from Ski Sundown?
- Snowboard Type :
- 6. Disc Golf
- What is the level of Disc Golf experience?
- 7. Kayaking
- What is the level of kayaking experience?
- Please provide any detail available on your kayaking experience. If you have an acquired disability did you kayak before injury or onset?
- 8. Skateboarding
- What is the level of skateboarding experience?
- 9. Climbing/Adventure Course
- What is the level of climbing or adventure course experience?
- Please list other sports or exercise you participate in:
- Have you participated in adaptive sports before, and if yes, did you use specialized equipment (please describe)?
- Primary Diagnosis
- Primary Diagnosis
- Please provide detail on your Blind or Low Vision Diagnosis
  For Example: How much can be seen? or Blind since birth or Depth Perception issues, etc...
- Please provide more information on the Mobility diagnosis:
  
  Other
- Please provide detail on your Mobility Impairment or Limb Loss Diagnosis
  For Example: SCI @ T12-Incomplete, Right Below Knee Amputation (RBKA), etc...
- Please Describe your Disability:
- Please provide more information on your Neuromuscular diagnosis:
  
  Other
- Please provide detail on your Neuromuscular Diagnosis
  For Example: Any Information that will help us prepare for your lesson.
- Please provide more information on your diagnosis (check all that apply):
  
  Other
- Please provide detail on your Cognitive, Intellectual, Learning Disability, Down Syndrome Diagnosis
  For Example: How may this impact a lesson, information we may need to plan a successful lesson, etc...
- Secondary Diagnosis if applicable
- Secondary Diagnosis if applicable. Please use the space to provide detail if needed.
- Please provide any additional information that may be helpful. If you have an acquired disability please tell us the date of injury or initial onset.
- Do you have allergies?:
- Please describe the allergies:
  (For example: severe nut allergy, seasonal, pollen, medication etc..)
- Do you carry an Epi Pen, and where is it located when you are participating in sports?
  (If you do not carry an Epi Pen, please write N/A or No in this section.)
- Do you have seizures currently or is there a history of seizures?
- Please describe type and frequency of seizures.
- Upload Physician Seizure form if available. If not available, please send to us at summitadaptivesports@gmail.com at least two weeks prior to your first scheduled activity.
  
  Cancelof
- Please list any medications currently taking that could have an effect on the lesson:
  (For example: make drowsy, frequent bathroom needs, sensitive to sun, etc..)
- To help us to select the best match of coach and plan your lesson please provide the following information on your (your family member's) behavioral and emotional histories.
- Anxiety
  
  1
  
  2
  
  3
  
  4
  
  5
  
  1 is None or NA, 5 is High
- If you have Anxiety please describe specifics that could be a trigger or make worse:
  (For example: crowds, loud noises, a certain animal, etc..)
- Confusion
  
  1
  
  2
  
  3
  
  4
  
  5
  
  1 is None or NA, 5 is High
- Distractibility
  
  1
  
  2
  
  3
  
  4
  
  5
  
  1 is None or NA, 5 is High
- Difficulty Following Directions
  
  1
  
  2
  
  3
  
  4
  
  5
  
  1 is None or NA, 5 is High
- Frustration/Tolerance
  
  1
  
  2
  
  3
  
  4
  
  5
  
  1 is None or NA, 5 is High
- Hostility
  
  1
  
  2
  
  3
  
  4
  
  5
  
  1 is None or NA, 5 is High
- Impulsivity
  
  1
  
  2
  
  3
  
  4
  
  5
  
  1 is None or NA, 5 is High
- Difficulty with Problem Solving
  
  1
  
  2
  
  3
  
  4
  
  5
  
  1 is None or NA, 5 is High
- Difficulty with Sequencing
  
  1
  
  2
  
  3
  
  4
  
  5
  
  1 is None or NA , 5 is High
- Slowness of Processing
  
  1
  
  2
  
  3
  
  4
  
  5
  
  1 is None or NA, 5 is High
- Speech or Communication Difficulties
  
  1
  
  2
  
  3
  
  4
  
  5
  
  1 is None or NA, 5 is High
- Trouble Understanding Safety
  
  1
  
  2
  
  3
  
  4
  
  5
  
  1 is None or NA, 5 is High
- Describe Communication Abilities
- Regarding Expressive Language, Please check all that apply:
  
  Other
- Regarding Receptive Language, Please check all that apply:
  
  Other
- Describe your most successful learning style (please choose one):
- Please share any additional information about communication needs or preferences that will help us prepare for the lesson?
  (For example: 'use 5 words or less when giving directions', or 'doesn't understand 'pizza' as ski wedge term, better to use triangle or letter V' )
- Please indicate if you have any of the following Physical Conditions:
  
  Other
- Please describe any visual issues and how it may impact the lesson:
  (For example: have tunnel vision)
- Please describe any hearing issues, devices worn, and how it may impact the lesson:
  (For example: often wears 1 of 2 cochlear implants under helmet)
- Please describe the amputation or limb loss:
- Please describe your hand/grip strength and is it different on each side?
- Do you use a wheelchair or something else for mobility?
  
  Other
- Wheelchair Transfers
  
  1
  
  2
  
  3
  
  4
  
  5
  
  1 is Independant , 5 is Need Assistance
- What is the size of your wheelchair seat cushion? (This information helps us plan which sit ski size is best for you.)
- Do you or your family member use the following medical device or ever had Autonomic Dysreflexia?
- Do you have any skin issues that we should be aware of? If yes, please describe below
- Will you benefit from more frequent breaks during our lessons (please choose one)?
- To help us better plan the level of support each individual may need during our lesson (for example: getting on and off the chair lift, getting up from a fall on snow, etc...) please describe the level of independence for the following listed below:
- Getting into and out of a car:
  
  1
  
  2
  
  3
  
  4
  
  5
  
  1 is Independent , 5 is Need Assistance
- Transition to and from the floor :
  
  1
  
  2
  
  3
  
  4
  
  5
  
  1 is Independent , 5 is Need Assistance
- Ability to balance on one leg:
  
  1
  
  2
  
  3
  
  4
  
  5
  
  1 is Independent , 5 is Need Assistance
- Ability to walk on uneven surfaces such as rock walkway or snow:
  
  1
  
  2
  
  3
  
  4
  
  5
  
  1 is Independent , 5 is Need Assistance
- By checking this box I agree that I have discussed my (my family member's) participation in sport lessons at Summit Adaptive Sports with my (their) primary physician and received a recommendation to participate.
- Will you (or your family member) be participating in ski or snowboard lessons with us at Ski Sundown?
- Summit Adaptive Sports collects information on Race/Ethnicty and Age in these ranges for the purpose of obtaining and reporting on grants that we receive. We appreciate your answering these next two questions.
- What race/ethnicity best describes you or your family member? Please check all that apply:
- Please describe your ethnicity/race here:
- What is your Age Range
- Summit Adaptive Sports is a member of Move United (an official Affiliate of the U.S. Olympic & Paralympic Committee & recognized partner with numerous sport organizations) and we share information with them for the purpose of identifying and qualifying for grants. Move United will send you copies of their periodic magazine and will not share your individual information with anyone else.
- Please Confirm Your Registration
  
  By checking this box and signing below I confirm that the information is the most current and accurate. I understand in order to provide a safe and fun experience, my (my family member) information may be shared as needed with 1) Summit Adaptive Sports coaches and volunteer staff, 2) medical professionals in case of emergency, and 3) as required for Summit Adaptive grant reports. I understand that it is my responsibility to inform Summit Adaptive Sports regarding any changes to my 1) contact information such as address, phone, and email and 2) any medical conditions including new diagnosis, surgery or medical changes that may impact my or my family member's participation in a lesson or program.
- Signature
- Date Completed Registration
  
  MonthDayYear
- Please verify that you are human
- Should be Empty: