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First Name: Last Name: Email: Phone: Address: City: State: Zip Code: - Employer:

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Birth Date (MM/DD/YYYY): / / Do you consider yourself a member of the Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, and/or Asexual (LGBTQIA+) community?

Yes

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I identify my gender as: I identify my race as:

White

Black or African American

American Indian or Alaska Native

Asian

Native Hawaiian/Other Pacific Islander

Prefer Not to Say

Not Listed

Disability category:

Acquired Brain Injury (Traumatic or Non-Traumatic)

Blind of Low Vision

Cognitive/Intellectual or Specific Learning Disability (Including Autism, Down syndrome, Severe ADD/ADHD, Nonverbal Learning Disability)

Deaf or Hard of Hearing

Dwarfism or Short Stature

Mobility Impairment and/or Limb Loss (including SCI, Spina Bifida, Transverse Myelitis, Amputation, Cerebral Palsy)

Neuromuscular (including ALS, Multiple Sclerosis, Charcot-Marie-Tooth disease, Muscular Dystrophy, Nerve Damage, Polio, Myopathy)

Not Listed (Describe below)

None

Disability: (select all that apply) Participant Type:

Athlete w. Disability

Family/friend/caregiver without disability

Veteran w disability

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Program Interests:

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Amputee Soccer

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