First Name: Middle Name: Last Name: Preferred Pronouns Address: Address Line 2 Address Line 3 Address Line 4 City: State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico U.S. Minor Outlying Islands Virgin Islands Armed Forces Americas Armed Forces Europe, the Middle East, an Armed Forces Pacific Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Territory Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory Zip: - Zip Suffix Phone: Additional Phone: Email: Email 2: Gender: Female Male I wish to not disclose Birth Date(MM/DD/YYYY): / / Disability Type Amputation Autism Cerebral Palsy Deaf/ Hard of Hearing Down Syndrome Multiple Sclerosis Muscular Dystrophy Post-Polio Syndrome Spina Bifida Spinal Cord Injury Stroke Visual Impairment Other No Disability If other, please specify Number of persons in Household Annual Household Income Under $20,000 $20,000 - $29,999 $30,000-$39,999 $40,000-$49,999 $50,000-$64,999 $65,000-$99,999 $100,000-$149,000 $150,000+ Prefer not to answer Race Black or African American (Not Hispanic or Latino) Asian (Not Hispanic or Latino) Hispanic or Latino Multi-Racial Native Hawaiian or Pacific Islander (Not Hispanic or Latino) Native American or Alaska Native (Not Hispanic or Latino) White Other Prefer not to answer Ethnicity Hispanic or Latinx Not Hispanic or Latinx Prefer not to answer Medical Restrictions Can you safely swallow liquids Health Insurance Medications Allergies Dietary Restrictions Level of SCI History of Seizures? Date of last seizure Please describe seizure (including type, frequency, triggers, length, severity) Prosthetic Limb Type: Select any mobility devices used by participant: Please describe participant's vision No limitations Mild/moderate impairment Severe impairment Blind/no vision Please describe participant's hearing: No Limitations Mild/ Moderate loss Severe loss Emergency Contact First Name Emergency Contact Last Name Emergency Contact Phone Number Emergency Contact Relationship Insurance Number Parent/Guardian/Caregiver Name Parent/Guardian/Caregiver Relation to Participant Has this individual ever served in the Military? Branch of Service How did you find out about the program? Years Served: Liability Waiver Media Release & Consent T-Shirt size (note: not all clinics or classes have t-shirts provided)