GENERAL INFORMATION
Participants Name
*
Describe Your Diagnosis/Disability
Parent/Caregiver Name
Date of Birth
Sex
Select
Male
Female
Age
Height
Weight
*DUE TO MANUFACTURE SAFETY STANDARDS
ADAPTIVE
Which program are
Select
Bolton Valley/Burlington
Sugarbush Resort
Pico Mountain
Address
City & State
Home Phone
*
Work Phone
Local Phone
E-mail
*
Emergency Phone
Emergency Contact/Relation
MEDICAL INFORMATION:
Primary Physician
Physician Phone
MOBILITY
Independent:
Select
Yes
No
Assistance required:
Select
Walker
Wheelchair
Crutches
Braces
GENERAL PHYSICAL CONDITION
Select One
Select
Excellent
Good
Fair
Past Surgical Procedures
Medications
Please list any allergies
Seizures
Select
YES
NO
If yes, controlled with medications
Select
YES
NO
If yes, please list medication
Type of Seizures
Describe Your SWIMMING Ability
Describe Your Past
For Horseback Riding:
MOTOR STATUS
Please select any difficulties with the following:
MUSCLE TONE
LOSS OF SENSATION
DECREASE OF STRENGTH
LIMBS
SPASTICITY
BALANCE
CIRCULATION IN RANGE OF MOTION
Misc Info
SECONDARY PROBLEMS
Diabetes
Vision Loss
Hearing Loss
Hearing Aid:
Select
YES
NO
Bladder Management: Self-Catheterization
Select
YES
NO
- Leg Bag:
Select
YES
NO
- Other
Do you suffer from chronic pain?
Select
YES
NO
If YES, list area affected:
How is your endurance?
Select
Excellent
Good
Fair
Does it decrease with activity?
Select
YES
NO
GENERAL ATTITUDE
& BEHAVIOR: 1. NORMAL: NO PROBLEMS
COMMUNICATION & PROCESSING:
Distractibility
1
2
3
4
Confusion
1
2
3
4
Problem Solving
1
2
3
4
Recall / Memory
1
2
3
4
Dyslexia
1
2
3
4
Disorientation
1
2
3
4
Ability to Follow Directions
1
2
3
4
BEHAVIORAL & GENERAL ATTITUDES:
Self Esteem
1
2
3
4
Self Control
1
2
3
4
Motivation
1
2
3
4
Goals
1
2
3
4
Anxiety
1
2
3
4
Frustration Tolerance
1
2
3
4
Anger
1
2
3
4
Temper
1
2
3
4
Impulsiveness
1
2
3
4
Self pity
1
2
3
4
Spatial Disorientation
1
2
3
4
Slowness of Speech
1
2
3
4
Ability to Self-Correct
1
2
3
4
Hostility
1
2
3
4
Follow Directions
1
2
3
4
Slowness of Cognitive
1
2
3
4
ACTIVITIES & SPORTS INVOLVEMENT:
Swimming
1
2
3
4
Weights
1
2
3
4
Running
1
2
3
4
Soccer
1
2
3
4
Sailing
1
2
3
4
Climbing
1
2
3
4
Basketball
1
2
3
4
Tennis
1
2
3
4
Archery
1
2
3
4
Biking
1
2
3
4
Water Skiing
1
2
3
4
Walking
1
2
3
4
Gymnastics
1
2
3
4
Rollerblading
1
2
3
4
Ice skating
1
2
3
4
Other
How did you learn
Previous ski/snowboard experience
Select
Skier
Snowboarder
Did you ski prior to your accident?
Select
Yes
No
N/A
Select one
Select
NEW
RETURNING
Approximate number of times
Type
Select
Beginner
Intermediate
Expert
Your goals regarding the ski season
Sit Down Skiers
If you have never skied before and are a potential sit-down skier, please read the paragraph below and answer the questions that follow.
Will rolling sideways onto your shoulders cause pain or injury to your back or shoulders, or cause dizziness?
Select
Yes
No
Using arm strength, can you push your own wheelchair independently?
Select
Yes
No
Within the past six months, have you had any injury to, or surgery on your back, spinal cord or hips?
Select
Yes
No
Do you wear a back brace?
Select
Yes
No
If yes, describe brace
Do you have Harrington Rods?
Select
Yes
No
If yes, lengths of time you've had them
Is there any reason to be concerned about the safety of
our staff, volunteers, or other clients due to this client?
Select
YES
NO
Any other important information that has not been mentioned:
Send request to
Water sports on lake Champlain
Cycling
Canoeing & Stoughton Pond
Skiing / snow sports & Pico
Skiing / snow sports & Sugarbush
Adaptive skiing at Bolton Valley
YES
I would like to enroll my child to participate in the DS/USA for this event, camp or program.
NO THANKS
I currently am not interested in enrolling my child to participate in the DS/USA Youth Sports Mentoring Program.
Please Send me information about the Paralympics and the Paralympic Movement!The Paralympics is a division of the US Olympic Committee and is dedicated to promoting the lives of people with Physical Disabilities
Please enter these numbers to complete this request.
