Athlete Registration

First Name: Last Name: Birth Date(MM/DD/YYYY): / / Height: Weight: Primary Phone: Email: I would like to be added to OAS' E-Newsletter list (usually 1-3 emails/month) Parent/Guardian/Caregiver Name Parent/Guardian/Caregiver Relation to Participant Home Address: City: State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico U.S. Minor Outlying Islands Virgin Islands Armed Forces Americas Armed Forces Europe, the Middle East, an Armed Forces Pacific Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Territory Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory Zip: - Zip Suffix Emergency Contact Name Emergency Contact Phone Emergency Contact Relation to Participant Emergency Contact Email Gender Identity (select all that apply) Race (select all that apply) Ethnicity Preferred Pronouns Do you identify as a member of the LGBTQ2S+ community? Yes No Prefer not to share Do you/athlete receive assistance from one or more of the programs: Medicaid, Unemployment, Social Security Disability Benefits, Supplemental Nutrition Assistance Program, Temporary Assistance for Needy Families, Free School Lunch Program, Aid for Dependent Children, Foster Care or any other similar state or federal financial assistance program? Yes No Disability or Diagnosis ADD/ADHD Amputee Amyotrophic Lateral Sclerosis (ALS) Arthritis Autism Blind/Visual Impairment Cancer/Cancer Survivor Cerebral Palsy Cognitive Delay Deaf/Hard of Hearing Developmental Disability Down Syndrome Emotional Disorder Fetal Alcohol Syndrome Learning Disability Multiple Sclerosis Muscular Dystrophy Non-Disabled Orthopedic Polio/Post-Polio PTSD Seizure Disorder/Epilepsy Spina Bifida Spinal Cord Injury Stroke/Stroke Survivor Traumatic Brain Injury Other (Please describe below) Fragile-X Syndrome Other (Please list below) Secondary Disability ADD/ADHD Amputee Amyotrophic Lateral Sclerosis (ALS) Arthritis Autism Blind/Visual Impairment Cancer/Cancer Survivor Cerebral Palsy Cognitive Delay Deaf/Hard of Hearing Developmental Disability Down Syndrome Emotional Disorder Fetal Alcohol Syndrome Learning Disability Multiple Sclerosis Muscular Dystrophy Orthopedic Polio/Post-Polio PTSD Seizure Disorder/Epilepsy Spina Bifida Spinal Cord Injury Stroke/Stroke Survivor Traumatic Brain Injury Other (Please describe below) Diabetes Disability/Diagnosis Detail: Cause of disability (if known) Year Disability Occurred (if applicable) Describe the athlete's mobility: Select any mobility devices used by participant: Describe athlete's ability to transfer (if applicable): Describe athlete's strength, mobility, and applicable limitations of upper extremities: Describe athlete's strength, mobility, and applicable limitations of lower extremities: Please describe athletes vision: Please describe athletes hearing: Describe the athlete's ability to communicate, including any assistive communication tools or devices if used: Please describe experience in sports or outdoor activities: Describe any motivators/stressors for athlete relevant to their participation with OAS: Please list any regular medications taken by participant: Does participant experience seizures? If yes, please describe seizure frequency and type: Date of last seizure (if applicable): Is athlete diabetic? If yes, does athlete use insulin? How is this administered? Please list any significant allergies that may impact participation: Has athlete experienced any major illnesses/Injuries in the past 12 months? If yes, please describe and include the date of illness/injury Please list any recent surgeries (within 12 months) that may impact participation: Is athlete cleared by a doctor to participate in athletics? Please list any other medical information that may be relevant to our outings? Has the athlete served in the Military? Number of years of Active Duty Military Rank Branch of Service Deployment Experience Captcha