Summit Adaptive Sports Participant Form

Welcome to Summit Adaptive Sports!

Summit Adaptive Sports is please to offer programing for Veterans and Members of the Armed Services who have a permanent disability as part of the Move United VA Adaptive Sports Grant Program for 2024 - 2025.

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 or need assistance completing this form please email us at summitadaptivesports@gmail.com or call Summit's office at Ski Sundown 860-379-7669 ext 221.

Steps to Register:

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

Step 2: At the end of the questionnaire you will receive a confirmation thank you page with links to our waivers to be signed electronically.

Step 3: A member of the Summit Adaptive Sports team will contact you to schedule your lessons.
- Participant Full Name
  
  First NameMiddle NameLast Name
- Please select:
- Guardian Full Name (If unable to sign for self):
  
  First NameLast Name
- Do you serve, or have you served, in the Military?
- Are you eligible for participating in VA Programs and are not debarred?
- What Branch of Military Service?
- What is your rank in the Air Force?
- What is your rank in the Marines?
- What is your rank in the Navy
- What is Your Rank?
- What is your rank in the Army
- Gender
- 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
- Height (feet and inches):
- Weight (lbs):
- Shoe Size:
- Shoe Type
- To help us schedule progarmming that best meets your needs please tell us if you would prefer to be in a group setting (with one-on-one coaching) or an individual setting, as well as best day and times for you.
- Are you interested in a Group Setting with other Military and Veterans?
- Would you be interested in having a family member or companion join you on the lesson?
- We are offering lessons at the dates and times list below. Please select all that you are interested in attending.
- We are offering a Veteran Event on Sunday September 8th and Monday September 9th. Please tell us the days you are interested in participating and if you need overnight accommodations (available if you live over 60 miles away).
- We offer Alpine Skiing and Snowboarding at Ski Sundown in the winter season and hope to be able to offer Nordic Skiing (X-Country or Telemark) depending on snow conditions. We also offer warm weather sports including Kayaking, Hiking, Disc Golf and soon to add Mountain Biking in the local area. Please indicate all sports you 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 rental Equipment?
- 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/Trail Riding
- What is the level of mountain biking/trail riding 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 rental equipment?
- 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. Sailing
- What is the level of sailing experience?
- 8. Curling
- What is the level of curling experience?
- Please provide any detail available on your curling experience. If you have an acquired disability did you curl injury or onset?
- Please provide any detail available on your sailing experience. If you have an acquired disability did you sail injury or onset?
- 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
- Secondary Diagnosis if applicable
- If you have an acquired disability please tell us the date and location the injury occurred. Type in 'NA' if not applicable.
- Please provide any additional information that may be helpful.
- 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 or Difficulty Following Directions
  
  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
- Frustration/Tolerance
  
  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 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
- 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:
- 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?
- 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 captures race and ethnicity information solely for the purpose of identifying and qualifying for grants to help our program. Answering this section is optional. What race/ethnicity best describes you or your family member? Please check all that apply:
- 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.
- Next Steps:
  
  Step 1: At the end of the questionnaire you will receive a confirmation thank you page with links to our waivers to be signed electronically. These need to signed.
  
  Step 2: A member of the Summit Adaptive Sports team will contact you to schedule your lessons.
- Signature
- Date Completed Registration
  
  MonthDayYear
- Please verify that you are human
- Should be Empty: