Adaptive Lesson Request Name* First Last Date of Birth*MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Sex* Height* Weight* # years Skiing/Snowboarding*Please enter a number less than or equal to 100.Previous Ski or Snowboard ExperiencePlease enter a number less than or equal to 0.Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code I prefer to be contacted by:*PhoneEmailEitherPreferred Date for Lesson*MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Preferred Choice of Lesson (2 hours each)*9-10 AM (cognitive 1 hour)12-2 PM2-4 PMOtherOther requested lesson time Phone*Email* Name of Emergency Contact/Parent/Guardian* First Last Phone of Emergency Contact/Parent/Guardian*Email of Emergency Contact/Parent/Guardian* Name of Participant's Physician* First Last Phone of Participant's Physician*MEDICAL INFORMATIONDescription of Disability*What major life function(s) does Participant’s disability affect:*Participant’s current activities and general energy level:*List medications Participant is currently taking and the reason why:*Has the Participant experienced a seizure within the past year?:*YesNoIf Yes, please indicate approximate date of last seizure:MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Participant allergies and severity:*Ability to sense cold:* Normal Impaired Unable Comprehension* Normal Impaired Unable Hearing Level* Normal Impaired Unable Vision Level* Normal Impaired Unable Verbal Communication* Normal Impaired Unable Lesson Type* Bi/Mono-Ski. 3-Track/4-Track. Adaptive Snowboard. Standard Equipment. See lesson type on Adaptive PageWill rolling onto your shoulders cause pain to your back or shoulders?* Yes No Using arm strength, can you push your own wheelchair independently?* Yes No Do you have Harrington Rods or a shunt?* Yes No Do you have any bowel or bladder adaptations?* Yes No If so, what?*If applicable, please note the level of your spinal cord injury:* Do you have the ability to maintain grip strength in your hands?* Yes No Level of Mobility*IndependentWalkerCrutchesBracesWheel ChairMotor Status*Please list any problems with muscle tone, range of motion, or strength.Adittional Health Issues*Please list any additional health problems such as, diabetes, cardiovascular problems, respiratory problems, etc.Lesson goals*What are your goals for the lesson. Δ
