MIDWEST ADAPTIVE SPORTS

Registration for our 4th Annual Tubing 101 and Winter Ski and Snowboard sessions are currently underway. Check out our calendar for details about each event!

Participant Information Form

*ALL INFORMATION WILL BE KEPT CONFIDENTIAL AND WILL NOT BE RELEASE TO THE PUBLIC*


PARTICIPANT INFORMATION: NEW Participant   RETURNING Participant
NAME:       NICKNAME: 
GROUP (If Applicable): 
PARTICIPANT'S MAILING ADDRESS: 
CITY:     STATE:      ZIP:      COUNTRY: 
HOME PHONE:      WORK PHONE:       CELL PHONE: 
PARTICIPANT’S OR FAMILY’S EMAIL ADDRESS (Your e-mail will only be used for MAS purposes and not sold to a 3rd party): 

*THANK YOU FOR GIVING US YOUR E-MAIL AS ALL OF OUR CORRESPONDENCE IS DONE VIA E-MAIL*
MALE   FEMALE         HEIGHT:      WEIGHT: 
BIRTHDAY:       RACE / ETHNIC ORIGIN (Optional): 

LEGAL GUARDIAN INFORMATION (IF APPLICABLE OR UNDER 18):
LEGAL GUARDIAN 1 INFORMATION: NAME:                      SAME HOME INFORMATION AS PARTICIPANT
MAILING ADDRESS: 
CITY:     STATE:      ZIP:     HOME PHONE: 

WORK PHONE:              CELL PHONE: 
PLACE OF EMPLOYMENT: 

LEGAL GUARDIAN 2 INFORMATION NAME:                      SAME HOME INFORMATION AS PRIOR GUARDIAN
MAILING ADDRESS: 
CITY:     STATE:      ZIP:     HOME PHONE: 

WORK PHONE:              CELL PHONE: 
PLACE OF EMPLOYMENT: 


EMERGENCY CONTACT INFORMATION: NAME:          RELATIONSHIP: 
MAILING ADDRESS: 
CITY:     STATE:      ZIP: 
HOME PHONE:      WORK PHONE:       CELL PHONE: 


PRIMARY PHYSICIAN’S NAME:           PHONE: 
PRIMARY HEALTH CARE FACILITY: 

MEDICAL INSURANCE COMPANY:            PHONE: 
MEDICAL INSURANCE POLICY NUMBER: 

GROUP CONTACT INFORMATION (IF APPLICABLE): ORGANIZATION NAME:      CONTACT NAME: 
MAILING ADDRESS: 
CITY:     STATE:      ZIP:           PHONE: 

MEDICAL INFORMATION:

PLEASE ANSWER ALL QUESTIONS BELOW:
PLEASE CHECK ALL THAT APPLY TO THE PARTICIPANT.  PROVIDE SPECIFIC INFORMATION WHERE REQUESTED.  ALL
INFORMATION IS VOLUNTARY AND REQUESTED ONLY TO ASSIST STAFF AND INSTRUCTORS IN PROVIDING QUALITY SERVICE.

PHYSICAL    
ALLERGIES AMPUTEE
(TYPE )
ARTHRITIS
ARTHROGRYPOSIS  ASTHMA BLIND / VISUALLY IMPAIRED
BRAIN INJURY CEREBRAL PALSY
(TYPE )
CONGENTIAL HEART DISEASE
CYSTIC FIBROSIS DIABETES DEAF / HEARING IMPAIRED
EPILEPSY FEEDING TUBE HEART PROBLEMS
(TYPE )
MULTIPLE SCLEROSIS MUSCULAR DYSTROPHY POST POLIO
RESPIRATORY DISEASE SHUNT SPINA BIFIDA
SPINAL CORD INJURY
(LEVEL )
STROKE
(LEFT / RIGHT )
OTHER (EXPLAIN)

     
MOBILITY    
CANES / CRUTCHES ELECTRIC WHEELCHAIR MANUAL WHEELCHAIR
INDEPENDENT    
     
DEVELOPMENTAL    
AUTISM DOWN SYNDROME MIND
MODERATE SEVERE / PROFOUND OTHER (EXPLAIN)
     
LEARNING DISABILITY    
ATTENTION DEFICIT DISORDER DISTRACTIBILITY DYSLEXIA
HYPERACTIVITY PERCEPTUAL OTHER (EXPLAIN)
     
BEHAVIOR    
ACTING OUT AGGRESSIVE SELF-ABUSIVE
OTHER (EXPLAIN)
   
     
EMOTIONAL    
ANTI-SOCIAL ANXIETY DEPRESSION
DISORIENTATION EATING DISORDER NEUROSIS
PSYCHOSIS SCHIZOPHRENIA SUBSTANCE ABUSE
OTHER (EXPLAIN)
   
     
COMMUNICATION    
VERBAL NONVERBAL
(TYPE )
 
     
VISUAL FIELD    
PLEASE DESCRIBE WHERE
THERE IS LIMITED VISIBILITY
   
LEFT EYE
RIGHT EYE
 

ADDITIONAL INFORMATION
SUBJECT TO SEIZURES?                 TYPE?                   FREQUENCY?

ALLERGIES TO FOODS OR MEDICATIONS? IF SO, PLEASE LIST:


CURRENT MEDICATIONS? IF SO, PLEASE LIST TYPE AND PURPOSE:


PLEASE EXPLAIN ANY BEHAVIORS OF WHICH STAFF SHOULD BE AWARE OF:


HOW DOES PARTICIPANT BEHAVE WHEN UPSET OR FRUSTRATED:


METHODS THAT WOULD MAKE LEARNING EASIER (VISUAL, VERBAL, TACTILE, ETC.):


ANY ADDITIONAL INFORMATION THAT WOULD BE HELPFUL FOR THE MIDWEST ADAPTIVE SPORTS STAFF TO BE AWARE OF?

PARTICIPANT RECREATION AND LEISURE INFORMATION: WHICH OF THE FOLLOWING BARRIERS RESTRICT PHYSICAL ACTIVITY?  CHECK ALL THAT APPLY.
LACK OF ENDURANCE LACK OF COORDINATION LACK OF MOBILITY LACK OF FLEXIBILTY
LACK OF STRENGTH OTHER?     

WHICH HUMAN DOMAIN IS THE PARTICIPANT HOPING TO DEVELOP THE MOST AT MIDWESET ADAPTIVE SPORTS?
NUMBER 1-5: 1 BEING THE MOST, 5 BEING THE LEAST.
  SOCIAL   EMOTIONAL   PHYSICAL   COGNITIVE   SPIRITUAL

WHAT EXPECTATIONS AS A PARTICIPANT DO YOU HAVE OF YOUR MIDWEST ADAPTIVE SPORT EXPERIENCE?


PLEASE WRITE A PERSONAL GOAL THAT CAN BE ACHIEVED THROUGH PARTICIPATION AT MIDWEST ADAPTIVE SPORTS:


THANK YOU FOR COMPLETING THIS FORM
AND PATICIPATING WITH MIDWEST ADAPTIVE SPORTS!

          

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