Adaptive Cycle Registration Form

Sports Association Adaptive Cycle Rides

2024 Registration Form
Thank you for your interest in the Gaylord Sports Association Adaptive Cycle Rides! To begin the registration process, please complete this form and we will contact you to schedule your first ride after receiving this form. Additional rides will be scheduled after attending your first ride. Once this form is submitted, you will receive the link to sign our annual waiver.
Participant Information
I would like to register for Adaptive Cycle Rides*

Yes
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
E-mail*
example@example.com
Date of Birth*

MonthDayYear
Emergency Contact*
Phone Number*
Please enter a valid phone number.
Relationship to participant*
What is your gender?*

MaleFemaleI prefer not to answer
Are you a Veteran?*

YesNo
How would you best describe yourself?*

WhiteAsian (Origin: example Chinese; Indian; Afghan; Filipino; Iranian; etc.)Black/African AmericanAmerican Indian or Alaska NativeNative Hawaiian or other Pacific IslanderPrefer not to answerOther
Are you of Hispanic/Latino/Spanish origin?*

No, not of Hispanic, Latino, or Spanish originYes, I am of Hispanic, Latino, or Spanish (Origin: example Mexican, Puerto Rican, Cuban, Dominican, Colombian, Spaniard, Ecuadorian, etc.)
T-shirt size.*
Height: *
Weight: *
Sports Association Membership
Have you participated in a Gaylord Sports Association Program in the past?*

YesNo
If you are not yet a member of the Gaylord Sports Association, or have not participated in a program in the last 3 years, please complete a member profile in addition to this cycle registration form. The member profile is an online form that is completed by all new members. Click here for the online form. Once the profile is completed, return to this form for cycling and continue completing this form.
What is your primary disability?*

AmputeeTraumatic Brain InjurySpina BifidaStrokeAcquired Brain InjuryMultiple SclerosisSpinal Cord InjuryVisual ImpairmentCOPDOther
Secondary Diagnosis (if applicable):
Please share any additional information about your disability below and/or provide any medical updates we should be aware of:
Program Registration
Have you participated in a Sports Association Cycle Ride or Cycle Clinic in the past? (New riders will be scheduled for a cycle fit prior to first ride).*

YesNoOther
Please tell us about your cycle experience (no experience, beginner, expert, rode prior to injury, etc): *
Please tell us about your equipment needs:*

I will be utilizing my own cycleI need to reserve an adaptive cycle
Type of cycle needed, brand/model (if known):
If you are aware of any specific modifications you may need, please describe below:
What are your goals for participation in this program?
Is there any other information that you would like to share with us that will help us to provide you with the best experience possible?
Once we receive your registration form, we will call you to schedule your first ride and reserve a cycle if needed.
Acknowledgment
By submitting this form, I verify that the above information is current and accurate. I understand that the above information will be kept confidential. In order to provide a safe and fun experience your information may be shared with: (1) Sports Association staff, coaches or instructors (2) other adaptive sports programs who will be working with you (3) medical professionals in case of emergency (4) as required for Sports Association grant reports. I understand that it is my responsibility to inform the Sports Association regarding changes to my: (1) contact information such as address, phone and email; (2) medical status including new diagnosis, surgery or medical changes; (3) any other information that is relevant to the safety of myself or others regarding my participation in Sports Association programs.
Signature

Clear
Liability and Media Waiver
All participants, volunteers, and coaches must sign an annual liability waiver and optional media release. Once this form is submitted, please follow the instructions on the submission page to sign the online waiver.
Should be Empty:

Sports Association Adaptive Cycle Rides

Participant Information

Sports Association Membership

Program Registration

Acknowledgment

Liability and Media Waiver