Paralympic Experience Individual Registration Form (One form per participant) Question Title * Level of Involvement Athlete Coach Family Member Volunteer Teacher Therapist Other (please specify) Question Title * Participant Contact Information First Name Last Name Age Date of Birth Gender Address (Street or PO Box) City State Zip Primary Phone Number (indicate if cell, home, or work) Email Address Question Title * Sport Involvement Recreational Developmental Emergin Elite/National Question Title * Sport Preference and Classification Sport Preference Sport Classification(s) Question Title * Disability (if applicable) Amputee Blind/Visually Impaired Cerebal Palsy Spina Bifida Spinal Cord Injury Traumatic Brain Injury/Stroke Other (please specify) Question Title * Are you a Veteran or active duty service member? Yes No Event Coordinators: Pam Carey 1-800-259-7200 x17; carey33452@aol.com; Stephanie Lamperez 337-519-3943; stephpt1@hotmail.com Done