Student Application 2011/2012

Submitted by AdaptiveSki on Wed, 10/21/2009 - 3:05pm.

Applications are accepted on a first-come first–serve basis.
Only COMPLETE applications are accepted.
Applications are approved after eligibility, payment and volunteer availability have been confirmed.

If you have no response to a required field (e.g. Secondary Phone) please mark with a zero.

Student Information

Name: *

# of years skiing/snowboarding: *

Address: *

City: *

State: *

Zip Code: *

Primary Phone #: *

Secondary Phone #: *

Email: *

Best way to reach you (phone / email): *

Date of Birth: *

Gender: *

Height: *

Shoe Size: *

Weight: *

Physician's Name: *

Physician's Phone #: *

EMERGENCY CONTACT INFO OR PARENT-GUARDIAN CONTACT INFO (if participant is a minor)

EC or Parent Name(s): *

EC or Home Phone: *

EC or Parent Work/Cell Phone: *

MEDICAL INFORMATION

Description of Participant’s disability: *

A letter from a physician, teacher or counselor may be requested to determine eligibility

What major life function(s) does Participant’s disability affect: *

Participant’s current activities / general energy level: *

List medications Participant is currently taking: *

Has the Participant experienced a seizure within the past year?: *

If so please indicate the approx. date of last seizure

List Participant’s food/medication allergies: *

Does Participant need to limit their activities for any reason?: *

Please check most appropriate answer:

Ability to sense cold: *

Normal

Impaired

Unable

Comprehension: *

Normal

Impaired

Unable

Hearing / Vision level: *

Normal

Impaired

Unable

Verbal Communication: *

Normal

Impaired

Unable

INDICATE PARTICIPATION PREFERENCES BELOW

Ski Area you want to participate at: *

Sandia Peak

Ski Santa Fe

Day of the week you wish to participate: *

Thursday (Santa Fe only)
Saturday
Sunday

Please list 1st and 2nd choices in order of preference.

Lesson Time preference: *

9:00 - 11:00am (Sandia Peak only)
10:00 - 12:00pm (Santa Fe only)
1:00 - 3:00pm

Please list 1st and 2nd choices in order of preference.

Please provide special requests or additional information we should know: *

Equipment Needs – PLEASE INDICATE TO THE BEST OF YOUR ABILITY: *

Outriggers with standard equipment -- Outriggers are handheld crutches with mini-skis on each end. Outriggers are for any stand up skier requiring extra balance.

Bi-Ski (Santa Fe skier weight must not exceed 200lbs., Sandia Peak 140lbs.) This sit down ski is for wheelchair users or those who have significant difficulty walking.

Mono-Ski (Santa Fe skier weight must not exceed 200lbs., Sandia Peak 140lbs.) This sit down ski is for spinal cord injuries

Standard Equipment (boots, poles and skis)

Snowboard (snowboard and boots)

Helmet (please note that ALL students are required to wear a helmet during lessons)

A doctor’s note may be requested to determine that participants are within the weight limits for bi and mono skis

THIS SECTION TO BE FILLED OUT BY SIT DOWN SKIERS ONLY

Will rolling onto your shoulders cause pain to your back or shoulders?:

Yes

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

Yes

Do you have Harrington Rods or a shunt?:

Yes

If applicable, please note the level of your spinal cord injury:

Do you have the ability to maintain grip strength in your hands?:

Yes

PARTICIPATION FEES – please submit payment with your application: *

If you are requesting scholarship assistance please fill out the scholarship request form and return with application.
Please print out the waiver, sign in both places and return with application.
Applications are not considered complete until waiver and payments have been submitted.

Student Application 2011/2012

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