First Name *

Last Name *

Who is completing this form? * Myself Parent/Guardian Spouse Sibling Caregiver/Personal Support Staff Friend Other

Participant's First Name *

Participant's Last Name *

Preferred Name or Nickname?

Age *

Birthdate (mm/dd/yyyy) *

Gender * Male Female Non-Binary Prefer not to say

Shoe Size *

T-Shirt Size * Small Medium Large XL XLT 2XL 2XLT 3XL 3XLT 4XL 5XL 6XL

Will the participant be attending programs with a family, group home, work shelter, classroom, or other non-school organization? *

If yes, please name the family, group or organization.

Will the participant attend programs with support staff? *

If yes, please provide their full name and phone number.

Primary Phone *

Primary Email *

Participant's Mailing Address *

City *

State *

Zip Code *

County * Antrim Charlevoix Cheboygan Emmet Otsego Other

Name of Parent/Legal Guardian (if applicable)

Parent/Legal Guardian's Phone (if different than above)

Emergency Contact Name *

Relationship to Participant *

Emergency Contact Phone *

Primary Disability Diagnosis (select all that apply) *

Specified Disability Diagnosis (select all that apply) *

If the participant's disability is not listed above, or you want to describe the disability in more detail, please respond below.

Please list any allergies or dietary restrictions. If not applicable, answer "none". *

Please list any medications taken during the day and what time. If not applicable, answer "none". *

Is the participant prone to seizures? *

If so, how often?

Does the participant carry an EpiPen? *

Please describe any special accommodations or modifications needed to participate. If not applicable, answer "none". *

Please describe any physical limitations. If not applicable, answer "none". *

If applicable, please describe the physical assistance level needed during activities: (supervision, hands on assist, minimum assist, moderate assist, total assist, etc.)

If applicable, please describe any medical equipment used during activities: (e.g., wheelchair, hearing aids, feeding tube, etc.)

Wheelchair type:

Do you require assistance for transfers?

Approximate time spent in wheelchair?

Please describe any unique behavior(s) to the participant. If not applicable, answer "none" *

Please describe the attendee’s preferred method of communication: (verbal, sign language, written, AAC device, tactile cues, etc.) *

What are the attendee’s goals for participating in a Challenge Mountain Program? (e.g., social interaction, skill development, fitness, etc.)

Anything else our staff should know to promote a safe and positive experience?

Please select all adaptive sports programs that you or the participant are interested in attending. *

Please select any art programs that you or the participant are interested in attending. *

Please select all programs that you or the participant are interested in. *

We are always looking to expand on our programs to fit the needs of the community. If you have an activity, sport, arts and crafts, living/learning skill building or another adaptive program idea, please feel free to list any thoughts below.

How did you hear about Challenge Mountain?