Intake Form: June 2026

PARTICIPANT INTAKE FORM

We require that you complete the information below with accurate and detailed responses in order to be considered. All forms are received by the REC Program Director and Coordinator and are strictly confidential.

GENERAL INFORMATION

First Name *

Last Name *

Email *

Gender *

Cell Phone (xxx-xxx-xxxx) *

Home Phone (xxx-xxx-xxxx)

Height (ex: 5' 11'' or 5-11) *

Weight in lbs. *For the safety of the skier and instructor, the maximum capacity for a downhill sit ski is strictly 200 lbs* *

Shoe Size *

Primary Language *

Birth Date *

ADDRESS INFORMATION

Primary Address *

City *

State *

Zip *

EMERGENCY CONTACT INFORMATION

Emergency Contact Name *

Emergency Contact Relationship *

Spouse

Partner

Son

Daughter

Mother

Father

Caregiver

Other

Emergency Contact Phone (xxx-xxx-xxxx) *

Emergency Contact Email *

PARENT/GUARDIAN INFORMATION

(If different from Emergency Contact)

Parent/guardian

Parent/guardian relationship

Spouse

Partner

Son

Daughter

Mother

Father

Caregiver

Other

Parent/guardian Phone (xxx-xxx-xxxx)

Parent/guardian Email

ADDITIONAL INFORMATION

What best describes you? *

What is your household income level? *

< $30,000

$31,000 - $60,000

$61,000 - $90,000

$91,000 - $120,000

$121,000 - $180,000

$181,000 <

PAGE 1/3

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

PARTICIPANT INFORMATION

Primary Disability/Diagnosis *

Secondary Disability/Diagnosis

Disability/Diagnosis Description: *

Which adaptive equipment have you used in the past? *

None

Bi-ski

Mono-ski

Slider or Rider Bar

Ski Bike

Bamboo pole or hula hoop

Other

Provide more information about the equipment you used, how many days have you been on snow with it, is it your own equipment etc. Otherwise please put N/A *

Please give us all necessary information related to your disability and how it presents itself: *this will help your instructor understand your specific needs and abilities, please be as detailed as possible *

Year of disability onset: *

Please list all allergies: (include food, environment, and medications) *If none, type N/A *

Please list all dietary restrictions: *If none, type N/A *

MEDICAL INFORMATION

Have you had a seizure in the past two years? *

Yes

Seizure Type

Seizures Controlled

Yes

Please list all medications, doses, side effects, and schedule: *Please note that Challenge Aspen Pros are not allowed to administer medication *If none, type N/A *

Altitude Sickness *

Yes

Motion Sickness *

Yes

Does participant carry an EpiPen? *

Yes

Please list all surgeries that may impact participants' Challenge Aspen experience: *If none, type N/A *

PHYSICAL INFORMATION

Sit Unassisted? *

Yes

Stand Unassisted? *

Yes

Walk Unassisted *

Yes

Use hands independently? *

Yes

N/A

Bear weight on legs? *

Yes

N/A

Does the participant have a shunt? *

Yes

Last shunt rev. date

Please describe all medical procedures, if any, as a result of the shunt:

Is the participant ambulatory? *

Yes

Primary assisted mobility *

None

Power Wheelchair

Manual Wheelchair

Cane

Walker

Crutches

Other assisted mobility

Endurance *

None

Poor

Fair

Average

Good

Excellent

Assistive Devices *

None

Braces

Other

Prosthetic(s)

Balance *

None

Poor

Fair

Average

Good

Excellent

Transfer Assistance *

No Assistance

Partial

Total

N/A

Hand Grip *

None

Poor

Fair

Average

Good

Excellent

N/A

Sores/Skin Breakdown *

Yes

N/A

Sores-when and where?

What triggers muscle spasms/tightness? *If none, please type N/A *

Spasms/Tightness-when and where?

Concerns with temperature or temperature regulation? *

Yes

Please describe temperature regulation issues and methods to resolve:

Extra sensitivity to the sun? *

Yes

Number of concussions: *If none, enter 0 *

Last concussion date:

Page 2/3

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

BEHAVIORAL INFORMATION

Please list intervention strategies or therapies used or involved in: *

Shows violence? *

Yes

Violence explanation:

Does the participant have an IEP or behavior plan? If yes, please include with the participant information *

Yes

Please list fears and dislikes: *

Please list/explain behavioral concerns: *

Attention to task *

Poor (0-1 minute)

Fair (1-5 minutes)

Average (5 minutes)

Good (more than 5 minutes)

Learning Style *

Visual-learns by seeing

Auditory-learns by hearing

Kinesthetic-learns by doing

Do you currently experience any of the following: *

Stress

Anxiety

Depression

Loneliness

Anger

Negative Behaviors

N/A

Please check the following that apply to you: *

A strong sense of desire to try new things.

Self-confidence

Seek more opportunities for recreation

Courage to challenge yourself

Independence

Happiness

Positive behaviors

N/A

SENSORY INFORMATION

Vision *

Totally blind

Partially sighted

Legally blind

N/A

Vision Description

Hearing *

Total hearing loss

Partial hearing loss

N/A

Auditory Sensitivity Description

Communication Method *

None

Conclear implant

ASL

English

Other

Other communication method(s)

PROGRAM SPECIFIC INFORMATION

Preferred instructor

Alternate instructor

Preference on instructor's gender? *

Female

Male

N/A

Ski or Snowboard *

Ski

Snowboard

Skill level *

Participated with other adaptive programs besides Challenge Aspen?

LEISURE INFORMATION

Accomplishments to date: *

Goals for your Challenge Aspen experience: *

Fun fact about yourself: *

You agree you are applying to participate in outdoor recreational and non-medically supervised programming. Participation includes activities that can be hazardous and involve risk of physical injury and/or death. You attest your current medical condition allows participation in these activities: *

Yes

Click me to edit...

You attest you have provided Challenge Aspen with ALL medical and disability information thereby allowing Challenge Aspen to make informed and safe decisions regarding your possible participation: *

Yes

Click me to edit...

By selecting "Yes" below, and hitting the Submit button, I understand and agree that I will not be considered to attend a program if the information I have provied above is not complete, honest, and accurate. *

Yes

By checking this box, I understand that Challenge Aspen staff, volunteers, and ski pros are not permitted to provide self-care such as toileting, changing and medication management. If this is a need for you, please make sure to have someone available to help with these tasks. *

Yes, I understand

Click me to edit...

By checking this box, I understand that I qualify for a full refund if I cancel my adaptive ski/snowboard lessons anytime before the 48-hour window. A cancellation within the 48-hour window of the lesson does NOT make me eligible for a refund. For Custom Adventures, Challenge Aspen requires 50% payment upon approval of the itinerary and payment in full 72-hours before the first day of participation. I am able to receive a full refund if I cancel prior to the 72-hour window leading up to the Custom Adventure. A cancellation within the 72-hour window does NOT make me eligible for a refund of any kind.

. *

Yes, I understand

Click me to edit...

**PLEASE NOTE: You will need to fill out the Challenge Aspen waiver, the DSUSA waiver, and a medical waiver, which you will receive in an email. They can also be found on our website.

**Please note: You are required to fill out the Challenge Aspen waivers and medical form, which you will receive via email or you can find on our website, if you have not completed already.

Page 3/3

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.