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* *

Primary Language *

Age *

Birth Date *

// (mm/dd/yyyy)

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