Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Birth Date

MM

DD

YYYY

Emergency Contact Phone *

(###)

###

####

Men's, Women's or Kid's Shirt?

Men's

Women's

Kid's

Size

S

M

L

XL

XXL

XXXL

Have you participated in adaptive waterskiing before? *

Yes

No

Did you get physician approval for participating in the event if less than 1 yr since your injury? *

Yes

No

Have you completed and passed the water-in-take test in the past 3 years? *

Yes

No

MEDICAL INFORMATION *

Participant's Disability

Autism

Brain Injury or illness

Stroke survivor

Spinal Cord Injury: paraparesis

Spinal Cord Injury: quadriparesis

MS

MD

Spina Bifida

Parkinsons

Amputee

Dwarf

PTSD

Down Syndrome

Neurological illness- ALS

Hearing impairment

Visual impairment

Intellectual challenges

Burn survivor

Other

Do you experience seizures? *

Yes

No

Are you currently taking any seizure medication? *

Yes

No

Do you have any open wounds? *

Yes

No

Would falling to the side cause injury to your back? *

Yes

No

Do you have a special medical condition we should know about ( i.e., asthma, diabetes, heart issues, etc)? *

Yes

No

Do you have Harrington Rods? *

Yes

No

Please check the activities you would like to participate in:

Adaptive Kayaking