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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@adaptivesportsconnection.org or call 614-389-3921.
PERSONAL INFORMATION
First Name *
Last Name *
Street *
Street2
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
Zip *
County *
Email *
Phone *
Birth Date *
Approx weight (lbs) *
Approx height (ft, in) *
Do you consider yourself a member of the Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, and/or Asexual (LGBTQIA+) community? *
Yes No Prefer Not to Say
I identify my gender as *
Female
Male
Non-Binary
Transgender
Cisgender
Prefer Not to Say
Prefer to Self Describe
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
I identify as being of Hispanic or Latino/a/x origin *
No, I am not Hispanic, Latino/a/x, or Spanish Origin Yes, I am of Hispanic, Latino/a/x, or Spanish Origin
Participant Type *
Athlete w. Disability Family/friend/caregiver without disability Veteran w disability Veteran w/o disability Volunteer
Code Here
Program Interests *
Kayaking Cycling Water Skiing Alpine Skiing/Snowboarding Amputee Soccer
How did you find out about ASC? *
EMERGENCY CONTACT Please provide a contact who will be available during the time you are at a Adaptive Sports Connection event.
Emergency Contact *
Emergency Phone *
Relationship to Participant *
PARENT/LEGAL GUARDIAN INFORMATION
Own Guardian *
YES NO
Complete this section if the volunteer is a minor or legally incapacitated.
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
If you have served in the military, then please complete the next section.
VA Eligible and not debarred
YES NO
Branch of Service
Air Force Army Coast Guard Marine Corps National Guard Navy Other
Military Rank
Service Connected Disability
YES NO
Did you serve post-911
YES NO
Home VA Office
MEDICAL INFORMATION
Do you have a disability? *
YES NO Prefer Not to Say
Disability/Diagnosis (please do not use acronyms)
Date of injury or onset
Disability category (select all that apply) *
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) *
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
Please explain any other disabilities
Assistive devices:
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
Other Assistive Devices - please explain
Are you able to walk? *
YES NO
If yes, for how long and how far?
If you use a wheelchair, are you independent with your transfers?
YES NO
Have you had surgery in the last six months? *
YES NO
If YES, then please describe:
Have you had a seizure in the last 24 months? *
YES NO
Date of last seizure
Currently taking medications? *
YES NO
If YES, please list all, including over-the-counter medications:
Allergies? *
YES NO
If YES, please list
Do you carry an EpiPen? *
YES NO
Medical details (please select all that apply)
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
Other disability Info
FINAL COMMENTS
Please provide any additional information that will help us create a successful experience for you.
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