LOF Adaptive Skiers- Participant Registration Bio Form
Please complete the following general, medical, and release information for participation in our ski events. This form is to be completed at the start of the season prior to the event and updated when information changes. Please contact the office at lofskiers@gmail.com or call 203-426-0666 with any questions.

Note on information sharing: LOF Adaptive Skiers often seeks grants and funds to keep our programs running and at times is asked to provide data about participants. This information is for non-commercial use and is kept confidential.
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Email *
Skier's Full Name *
Nickname
Skier's Date of Birth *
MM
/
DD
/
YYYY
Gender *
Email *
Please note that we send pertinent information via email.  Please check your emails regularly to stay up to date.
Phone Number *
Please indicate whether or not we can leave a message and with whom are we communicating with when calling
Mailing Address *
Emergency Contact Name and Relationship *
Emergency Contact Phone number *
Height *
(In feet and inches)
Weight *
(In pounds)
Are you active military, retired, veteran, or reserves? *
If yes, please list rank and branch
Medical Information: Diagnosis or disability (primary and secondary) *
Date of injury/illness/diagnosis
MM
/
DD
/
YYYY
Do you have or have you had seizures? *
Date of last seizure
MM
/
DD
/
YYYY
Mobility and equipment used (i.e. wheelchair, crutches, walker, bracing) *
Please inform us of any implants or medical devices (i.e. pacemaker, artificial joints)
Medications- please list any active medications and side effects *
Does the skier have any allergies or dietary restrictions? *
LOF lunches typically include pizza, grinders, or barbeque (hotdogs/hamburgers).  Participants who have dietary restrictions and cannot eat these foods should plan to bring a brown bag lunch and/or snacks.
Primary physician and contact information *
Athlete's Authorization and Release of Liability: I know of no reason why my participation in these or any sporting events provided should be exceptionally or unusually hazardous. I or my legal guardian have considered the risk that I may be physically injured as I prepare and participate in these events and I assume such risk. I intend this to be a complete release and discharge of all persons as well as any corporate entities having anything to do with this event and I intend hereby to release and forever discharge said persons from all liability what so ever. I have read all of the statements contained herein and I fully realize that I am signing complete release and bar to any further claims which I may have resulting from my participation in these events. *
Please provide signature
Consent to Treat: I give my consent for LOF Adaptive Skiers volunteers, personnel, staff, and qualified medical personnel who are called to treat me in an emergency situation. I agree to pay for medical treatment and transportation costs incurred on my behalf. *
Signature and date required
Motion impairment *
(check all that apply)
Required
Balance and Coordination *
(check all that apply)
Required
Weakness *
(check all that apply)
Required
Impaired feeling and sensation *
(check all that apply)
Required
Vision *
(check all that apply)
Required
Communication *
Behavioral (i.e. strategies, triggers, motivation) *
Hearing *
(check all that apply)
Required
Please use the space below to provide any additional information that may be of use to our instructors.
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