Adaptive Track & Field Clinic Feb 23

* 1. What is your first name?

* 2. What is your last name?

* 3. What year were you born?

* 4. In what ZIP code is your home located? (enter 5-digit ZIP code; for example, 00544 or 94305)

* 5. Please provide a contact e-mail

* 6. What grade are you in?

7th grade

8th grade

9th grade

10th grade

11th grade

12th grade

High School Track & Field Coach

Other (please specify)

* 7. If you have a visual or mobility impairment, check one or more boxes to tell us about it:

Totally blind

Visually impaired

Use a manual wheelchair

Use a power wheelchair

Have one or two leg prosthetics

Use crutches or a walker

Tell us in your own words

* 8. Have you competed on your school's Track & Field team before? (Indoor or outdoor)

Yes

No

* 9. Which Track & Field disciplines interest you?

Running Sprints (100m-400m)

Running Mid/Long (800m-2mile)

Wheelchair Sprints (100m-400m)

Wheelchair Mid/Long (800m-2mile)

Jumps

Throws

* 10. If you are blind or visually impaired, will you bring a friend as a guide?

Yes

No