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

Gender * Male Female Non-Binary Prefer not to say

Age *

Birthdate (mm/dd/yyyy) *

Approximate Height (feet/inches) *

Approximate Weight (lbs.)

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

Shoe Size *

Shoe Size (cont.) *

Participant's Mailing Address *

City *

State *

Zip Code *

County of Residence * Antrim Charlevoix Cheboygan Emmet Otsego Other Within Michigan Other Outside of Michigan

Primary Email

Primary Emergency Contact Name *

Primary Emergency Contact Phone *

Relationship to Participant *

Secondary Emergency Contact Name (not required)

Secondary Emergency Contact Phone (not required)

Relationship to Participant (not required)

Any additional contacts you would like to include? Please provide name, phone and/or email.

Will the participant attend programs with support staff? *

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

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.

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

Please list any allergies or dietary restrictions. 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:

Assistance required 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?