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Participant Profile

Thank you for taking the time to complete your profile. It is important to have current information to help us make your experience safe and more enjoyable.

Any questions? Contact info@taasc.org or call 614-389-3921.

 

 

PERSONAL INFORMATION

// (mm/dd/yyyy)

   

Female
Male
Non-Binary
Transgender
Cisgender
Prefer Not to Say
Prefer to Self-Describe

   

White
Black or African American
American Indian or Alaska Native
Asian
Native Hawaiian or other Pacific Islander
Prefer Not to Say
Not listed

   

No, I am not Hispanic, Latino/a/x, or Spanish Origin
Yes, I am of Hispanic, Latino/a/x, or Spanish Origin

   

Yes
No
Prefer Not to Say

   

Kayaking
Cycling
Sailing
Water Skiing
Alpine Skiing/Snowboarding
Climbing
Amputee Soccer

 


 

EMERGENCY CONTACT

Please provide a contact who will be available during the time you are at a Adaptive Sports Connection event.

 

 


 

PARENT/LEGAL GUARDIAN INFORMATION

 

 

YES
NO

 

Complete this section if the volunteer is a minor or legally incapacitated.

 


MILITARY ONLY

 

 

If you have served in the military, then please complete the next section.

 

   

YES
NO

   

Air Force
Army
Coast Guard
Marine Corps
National Guard
Navy
Other

   

   

YES
NO

   

YES
NO

   


MEDICAL INFORMATION

 

YES
NO

   

   

   

Able-bodied
Amputee - arm
Amputee - multiple
Amputee - above knee
Amputee - below knee
Amputee - leg
Aspergers
Autism
Cardiac/Heart condition
Cerebral Palsy
Diabetes
Down syndrome
Hearing Imparement - Total
Hearing Imparement - Partial
Multiple Sclerosis
Muscular Dystrophy
Post Traumatic Stress Disorder
Respiratory condition
Spina Bifida
Spinal Cord Injury
Stroke
Traumatic Brain Injury
Visual Impairment - Total
Visual Impairment - Partial
Other

   

   

AFO/Leg braces
Ambulatory
Cane
Crutches
Manual wheelchair - part time
Manual wheelchair - full time
Power wheelchair - part time
Power wheelchair - full time
Prosthetics
Walker
Other

   

   

YES
NO

   

   

YES
NO

   

YES
NO

   

YES
NO

   

   

YES
NO

   

YES
NO

   

YES
NO

   

Limited range of motion in any limbs
Difficulty with balance
Wear any sort of spinal stabilization
Any type of paralysis
Sensitivity to hot or cold
Difficulty speaking or communicating
Difficulty remembering or following directions
Emotional and/or behavioral concerns we should know about
Cognitive or developmental delay
Heart/cardiac condition
Respiratory condition

   

 


 

FINAL COMMENTS

 

   

   


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