First Name *

Last Name *

Email *

Phone *

Address Line 1 *

Address Line 2

City *

State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico U.S. Minor Outlying Islands Virgin Islands Armed Forces Americas Armed Forces Europe, the Middle East, an Armed Forces Pacific Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Territory Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory

County *

Zip Code *

Additional Details

Birth Date *

Approx weight (lbs) *

Approx height (ft, in) *

Including yourself, how many family members in your household? (please enter number only) *

Do you consider yourself a member of the Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, and/or Asexual (LGBTQIA+) community? *

I identify my gender as * Female Male Non-Binary Transgender Cisgender Prefer Not to Say Prefer to Self Describe

I identify my race as *

I identify as being of Hispanic or Latino/a/x origin *

Participant Type *

Program Interests *

How did you find out about ASC? * Search engines (Google, Bing, etc.) Facebook Instagram YouTube X / Twitter In-person events or trade shows Word of mouth Referral by friend or family Referral by colleague Referral by volunteers TV or radio mentions Blog/Resource Other (Please specify below)

Please specify what other ways you found out about ASC

Employer

Emergency Contact

Emergency Contact *

Emergency Phone *

Relationship to Participant *

Parential / Legal Guardian Info

Own Guardian *

Guardian Name

Relationship

Guardian Street Address

Guardian City

Guardian State

Guardian Zip

Guardian Email

Best phone number to reach guardian

Military Only

Veteran Y/N * YES NO

VA Eligible and not debarred

Branch of Service

Air Force Rank 1SGT 1stLT 2ndLT A1C AMN BRIGGEN CAPT CCM CMSAF CMSGT COL GEN LTCOL LTGEN MAJ MAJGEN MSGT SMSGT SRA SSGT TSGT

Army Rank 1LT 1SG 2LT BG CAPT COL CPL CSM CW2 CW3 CW4 CW5 GEN LTC LTG MAJ MG MSG PFC PV2 PVT SFC SGM SGT SMA SPC SSG W01

Marines Rank 1SGT 1stLT 2ndLT BGEN CAPT COL CPL CW02 CW03 CW04 CW05 GEN GYSGT LPCL LTCOL LTGEN MAJ MAJGEN MGYSGT MSGT PFC PVT SGT SGTMAJ SGTMAJMC SSGT W0

Navy Rank ADM CAPT CDR CPO CW02 CW03 CW04 ENS FADM LCDR LT LTJG MCPO MCPON PO1 PO2 PO3 RADM RDML SA SCPO SN SR VADM

Please provide your military rank if not listed in the branch rankings above

Service Connected Disability

Did you serve post-911

Home VA Office

Do you have a disability? *

Disability/Diagnosis (please do not use acronyms)

Date of injury or onset

Disability category (select all that apply) *

Disability (select all that apply) *

Medical details

Other or additional disability info

Assistive devices:

Other Assistive Devices - please explain

Are you able to walk? *

If yes, for how long and how far?

If you use a wheelchair, are you independent with your transfers?

Have you had surgery in the last six months? *

Have you had a seizure in the last 24 months? *

Date of last seizure

Currently taking medications *

If YES, please list all, including over-the-counter medications:

Allergies? *

If YES, please list your allergies

Do you carry an EpiPen? *

Final Comments

Please provide any additional information that will help us create a successful experience for you.