Student Enrollment Application Form printable pdf download

SKI APACHE ADAPTIVE SPORTS

P.O. BOX 2138

RUIDOSO, NM 88355

STUDENT ENROLLMENT APPLICATION

DATE_______________

PLEASE PRINT CLEARLY

STUDENT’S NAME______________________________________________________

Phone #_____________________e-mail_______________________________________

Address_________________________________________________________________

City, State______________________________________________Zip______________

*Age_____Sex_____Height________Weight________Shoe size___________________

CHECK ONE: ___ Ski today ___ Snowboard today

Parent/contact person___________________________________Phone#_____________

MEDICAL INFORMATION

Description of Disability)_____________________________________________

________________________________________________________________________

Seizures: Yes_____No____*Date of Last Seizure_________Type__________________

Medications: Yes_____No_____Type_________________Affects__________________

Note: High altitude (Ski Apache base is 9600’) may alter the effects of medications

Permanent conditions or medical apparatus we should be aware of (eg. Harrington Rods,

shunts, catheters, etc.)_________________________________________________

________________________________________________________________________

If paralysis, where on spine:_________________________________________________

If head injury, explain______________________________________________________

________________________________________________________________________

Doctor/Therapist______________________________________ Phone#_____________

SKIER/SNOWBOARDER INFORMATION

(Never-ever)____(Skied before)_____Number of times?____Where?________________

Activities, sports, hobbies:__________________________________________________

_______________________________________________________________________

Boots_________________Skis/SB________________________Helmet_____________

INSTRUCTOR FEEDBACK

Instructor name___________________________________________________________

Adaptive equipment_______________________________________________________

Reinforcers/triggers_______________________________________________________

Chairs?_____________________ Reminders? _________________________________

Additional comments on back:_______________________________________________

SAFETY FIRST!

*Everyone 17 years of age and younger MUST wear a helmet

*If you have had a seizure within the past two years, you MUST wear a safety harness

Student Enrollment Application Form