1. Adaptive Sports Youth Clinic

You have entered a secure online registration system.

In this system you may register for our Adaptive Sports Youth Clinic and MORE IMPORTANTLY complete a Medical and Liability Waiver.

One form PER PARTICIPANT

NOTE: Questions marked with an * require all fields be completed. If a particular question does not apply please enter n/a.

* 1. Will you be attending our adaptive sports youth clinic on Saturday, March 8th [3:30-5pm] at the Raleigh Convention Center [500 Salisbury Street, Raleigh, NC]?

* 2. Enter PARTICIPANT'S name:

* 3. All participants will attend free of charge. Each participant may also designate [4] guests who may also attend free of charge. Please provide us with the names of those you would like added to the guest list:

* 4. Enter PARTICIPANT'S gender:

* 5. PARTICIPANT'S Age:

* 6. PARTICIPANT'S Birthdate:

Birthdate
/
/

* 7. Please enter school information for the PARTICIPANT:

* 8. How did you become aware of this opportunity?

* 9. Will the PARTICIPANT be using an Assistive Device? If so, please indicate:

* 10. All PARTICIPANTS must be able to perform the following tasks [or be accompanied by a 'personal care provider']:

1] Dress and eat without assistance.
2] Perform all aspects of personal hygiene.

* 11. PARTICIPANT'S physical disability [define below]?

* 12. PARTICIPANT'S who are amputees, please indicate location:

* 13. Health Information for PARTICIPANT [OPTIONAL - this information will only be shared with emergency medical care providers if there was an emergency during the event].

* 14. Any Additional Notes:

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