NSCD 2018 Precision Clinic

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What: This camp may include Shooting sports, Rock Climbing, Boxing, Dance, Yoga, Slackline, Progresh, and NSCD Moves! Course. At the NSCD we believe that through the personal challenge, and enriching atmosphere of the outdoors participants can learn important lessons about themselves and others as well as increasing their overall fitness and quality of life.

When: January 2nd-6th

Ages: 13-50

How much: $400 per athlete

Camp Logistics:
- Drop off at Mile High Stadium (1801 Mile High Stadium Circle in the upper part of Lot L) between 7:30am-8:00am
- Pick up at Mile High Stadium (1801 Mile High Stadium Circle in the upper part of Lot L) between 4:00pm-5:00pm
- Because a portion of these activities are outdoors, certain activities may need to be altered or locations changed due to weather and conditions. We will let you know of any program changes as soon as is possible.

Things to Bring:
o Sunscreen
o Water bottle (full of water)
o NON COTTON active clothing & Layers for possible cold weather
o Lunch
o Sunglasses
o Active footwear (no sandals)
o Any other personal care items.

Please come to the first day of camp with a hard copy parent signed 2017 Liability Waiver - http://nscd.org/wp-content/uploads/2016/12/NSCD-Non-Skiing-Ability-Clinics-Camps-Programs-Release-2017-w-Zip-Code-FINAL.pdf

Please e-mail mgabbianelli@nscd.org if you have any questions, thank you.

Untitled Title

Participant First Name *

Participant Last Name *

The camper participating is a... *

Participant with a disability

Participant without a disability

Are you : *

A Veteran of the US Armed Forces

Currently a member of the US Armed Forces or Reserve

Required

Does the participant qualify for or receive assistance from one or more of the following programs: Free and Reduced Price School Lunch, Medicaid, Unemployment, Social Security Disability Benefits, Supplemental Nutrition Assistance Program, Temporary Assistance for Needy Families, Aid for Dependent Children, Foster Care, or other similar state or federal financial assistance programs? This information is used to compile statistics that are crucial for our funders and will not be considered for any other purpose. *

Yes

Unknown

Prefer not to answer

Street or PO Box Mailing Address *

City *

State *

Zip code *

Email Address *

Home or Cell Phone

Date of Birth *

YYYY

Primary Diagnosis *

Please list all diagnosis, If no diagnosis, please write "NONE."

Cognitive effects of diagnosis *

Physical effects of diagnosis *

Behavioral effects of diagnosis *

Seizures *

YES

If Yes, date of last seizure?

YYYY

Frequency

Type

If Yes to seizures, please list all medications (name, dose, frequency, effects and side effects)

Can you tell if seizure is going to occur?

YES

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Food allergies/Dietary Restrictions please list *

Height

Weight

Shoe size

How do you ambulate? *

Walk Independently

Cane

Crutches

Walker

Manual Wheelchair

Electric Wheelchair

How do you communicate? *

Verbal

Non-verbal

ASL or other

Other:

Hearing *

Hearing

Deaf

Deaf right

Deaf left

Hearing aids both

Hearing aid right

Hearing aid left

Cochlear implant

Other:

Vision Field

Blind

Impaired

Other:

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Describe your visual field and blackout areas.

List any restricted activities. *

Please list any medications you are currently taking. *

Can you self-administer medication needed during activities?

YES

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What is your goal for this program session? *

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