Private Lesson Application 2009/2010

Submitted by AdaptiveSki on Thu, 10/08/2009 - 2:01pm.

Please fill out the entire Private Lesson application. Applications are accepted on a first come first serve basis. Only complete applications are accepted. Please review the eligibility guidelines before submitting your application. If you have any questions about these guidelines, please contact Katya at 505-955-9858.

Please give at least two weeks notice from lesson date. Fill in n/a if a required field is not applicable.

Name: *

Email: *

Address: *

City: *

State: *

Zip Code: *

Cell Phone: *

Home Phone: *

Phone# while visiting NM: *

Have you adaptive skied before?: *

When/Where did you ski last?: *

If Skier is a Minor / Emergency Contact Info

Parent / Emergency Email:

Parent / Emergency Name(s):

Parent / Emergency Phone:

MEDICAL INFORMATION

Participant's Age: *

Participant's Date of Birth: *

Participant's Height: *

Participant's Weight: *

Description of participant’s disability: *

Major life function(s) affected by participant's disability: *

Participant’s current activities and general energy level: *

Participant's current medication(s) list: *

Participant's seizure history and date of last seizure: *

List known allergies: *

Is participant ambulatory? What % of the time?: *

Limitations to participant's activities? Please explain: *

Participant's Hearing Level: *

Normal

Impaired

None

Participant's Depth of Vision: *

Normal

Impaired

None

Participant's Peripheral Vision: *

Normal

Impaired

None

Participant's ability to communicate verbally: *

Normal

Impaired

Unable

Participant's ability to sense becoming cold: *

Normal

Impaired

Unable

Participant's ability to understand instructions: *

Normal

Impaired

Unable

Participant's special medical conditions and other important information: *

Please indicate your equipment needs: *

Outriggers and regular skis. (Outriggers are hand held crutches with mini-skis mounted on each end. They are used in place of poles when extra balance is required. Those who walk using crutches, canes or walkers typically use outriggers. They are a necessity for above-the-knee amputees or below-the-knee amputees with a less than 4" stump.)

Bi-Ski (Bi-ski users must weigh less that 200 lbs. The bi-ski is designed for those who use a wheelchair or have difficulty walking, even when assisted by crutches, canes or walkers. Bi-skiing candidates also include traumatic head injuries, high-level (T7 and up) paraplegics, quadriplegic and those who have been unsuccessful in stand-up skiing.)

Mono Ski (Mono-ski users must weigh less than 200lbs. Best for individuals who use a wheelchair, who are athletic and in good physical shape. The mono ski was designed for individuals with spinal cord injuries

Standard Equipment (regular boots, poles, skis. You will need to be pre-fitted for your size, prior to the first day of lessons. Information on where and when to be fitted will follow by mail.)

Snowboard & Boots (limited availability)

Helmet (ALL ASP students are required to wear a helmet during their lessons.)

Please note that your equipment is included in the price of the lesson. If you choose to rent at a location other than Ski Santa Fe
it will NOT be included. During peak times, the rental line can be very lengthy. Please plan accordingly. If you have any
questions please call the main office at the number on the top of this application.

This Section to be filled out by sit-skiers only

For safety purposes, a skier’s weight must not exceed 200 lbs. Adaptive ski equipment is not designed for use beyond this weight. (Note that this is for Santa Fe. Participants joining us at Sandia Peak must weigh less than 140lbs.)

In the chairlift unloading process, safe as it is, your hips and back must be able to sustain the slight "jolt" that occurs when transferring from the chair to the snow.

Will rolling sideways onto your shoulders cause pain, injury or dizziness?:

Yes

Using arm strength, can you push your own wheelchair independently?:

Yes

Do you have a spinal cord injury? If so, what level is the injury?:

Have you had any recent injury to, or surgery on, your back, spinal cord or hips?:

Yes

Do you wear a back brace or have Harrington Rods?:

Yes

Does your disability cause weakness on one side or in your hand-grip ability?:

Yes

I am aware of the weight restrictions and testify that the weight given is accurate.:

Yes

PRIVATE LESSON RATES
Rates are for Santa Fe Only. If you want to ski at Sandia Peak please call the office as availability is limited

$100 Full-Day lesson (4 hours) Full day lessons are from (10:00-12:00 and 1:00-3:00)

$75 Half Day lesson (3 hours) Half day lessons are from (10:00-1:00 or 1:00-4:00)

Please note: Based on snow conditions and availability we may request a 9:00 start time for some lessons.

Date(s) you wish to ski:

Lesson Time:

AM Half Day

PM Half Day

Full Day

Are your dates and times flexible?:

If yes, please describe

Please remember that all of the ASP instructors are volunteers and are clearing their schedules to ski with you while you while you visit. If your plans change please notify us immediately so they can re adjust their schedules. If you arrive late for a lesson, your instructor may not be able to continue passed the scheduled lesson time. Thank you.

When submitting this application please complete the waiver of liability by signing in both places (in blue or black ink) and returning with the application. If you do not want the ASP to use any photos, video, and or film of you please indicate “no” on the waiver – do not leave blank. If choosing to pay by check, please include full payment with liability form. Both the liability form and payment are needed two weeks prior to lesson to guaranty availability.

THINK SNOW!!!

Private Lesson Application 2009/2010

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