Ski Registration Form

Ski & Snowboard Registration Form
Please complete this form if you would like to participate in the Gaylord Sports Association Adaptive Ski & Snowboard Program at Ski Sundown in New Hartford, CT. Please review the information packet to review the program policies, procedures and list of required forms prior to participation. Once we recieve this form, we will contact you to confirm your lesson dates and times.
I would like to register for the 2023 Gaylord Sports Association Ski and Snowboard Club:*

Yes
Participant Information
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
Height*
Weight*
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.)
Emergency Contact*

First NameLast Name
Relationship*
Phone Number*
Please enter a valid phone number.
Are you your own legal guardian?*

YesNo
If you are not your own legal guardian, your legal guardian or legal representative must sign the waiver & release of liability agreement on your behalf.
Legal Guardian Name

First NameLast Name
Legal Guardian Relationship
Legal Guardian Phone Number
Please enter a valid phone number.
Sports Association Membership
Have you participated with the Gaylord Sports Association in the past?*

YesNo
As part of this program, we ask all participants to complete a new and updated Member Profile. Thank you!

Link to Member Profile form: https://hipaa.jotform.com/203385423642150. After completing profile, please return to this form and complete.
Medical Update
What is your primary diagnosis?*

Spinal Cord InjuryTraumatic Brain InjuryMultiple SclerosisStrokeAcquired Brain InjuryAmputeePTSDSpina BifidaVisual ImpairmentOther
Please describe any medical changes or surgeries you have had in the last year, or since the last time you participated with us:
Please make any additional comments about your disability or medical history that we should be aware of.
Ski & Snowboard Information
What are your goals for participation in this program? *
Which of the following best describes your skill level?*

First timerFirst time since injury or illnessBeginnerIntermediateAdvancedOther
How do you anticipate participating in the lessons?*

Sit-SkiStand-up Ski, with or without adaptive equipmentSnowboard (stand)Not sure
What equipment do you use (if known)?*

Standard equipment (skis or snowboard)Sit-Ski (Bi-Ski)Sit-Ski (Mono-Ski)Stand with outriggersNot SureOther
If planning to snowboard which foot is forward on the board?(If not snowboarding, leave blank.)

RightLeftNot SureNever used a snowboard before
If you are a sit-ski athlete, what is the width of your everyday wheelchair seat?
If skiing or snowboarding, what is your boot size?
Please indicate if boot size is men's or women's.

Men'sWomen's
Will you be bringing any equipment with you including skis, sit ski, wheelchair, walker?*

YesNo
If yes, please specify:
Will you be bringing a companion to assist with personal care?*

YesNo
If yes, who will be attending with you and what is the relationship?
Name of companion:
Relationship to skier:
If yes, will your companion ski with you? Companion tickets may be purchased for $35.00. (If your companion would like to ski on their own, a regular lift ticket must be purchased). Sports Association staff is not trained to provide personal care assistance or administer medication.

YesNo
What is your transportation preference?*

Drive SelfGaylord Bus(Meets at Gaylord, Limited capacity)
Please select the trips you would like to attend. We will notify you with the first two lessons we were able to accommodate you on. Once you participate in your first lesson, you may register for the next available lesson. All trips are to Ski Sundown in New Hartford, CT.*

Saturday, Jan. 7, 2023, 1:00-3:30pmSaturday, Jan. 21, 2023, 1:00-3:30pmMonday, Jan. 30, 2023, 5:30-8:00pmSaturday, Feb. 4, 2023, 1:00-3:30pmSaturday, Feb. 25, 2023, 1:00-3:30pmMonday, March 6, 2023, 5:30-8:00pm
Payment Information
The cost per skier, per lesson is $50.00. Payment must be received at the time of your reservation.

Payment may be made online at: www.gaylord.org/sportspay. Please pay for ONE lesson to start. Additional payments can be made when you receive confirmation from the Sports Association that you are scheduled for your next lesson. If you are registering after Jan 21st, please wait for us to confirm your lesson date before making a payment.

If a participant cancels less than 7 days prior to lesson, we will not be able to provide a refund unless there are extenuating circumstances.

For payment by check, please make check payable to Gaylord Hospital, Inc.; Please write in memo section: Sports Association Ski Trip and date of trip. Checks may be mailed to:

Gaylord Hospital

Attn: Sports Association

50 Gaylord Farm Rd

Wallingford, CT 06492
I will pay for outing(s) by:*

Online Payment (pay one outing fee of $50 to start)Mail a check
Please let us know if you have any questions or other information to share with us:
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
Should be Empty:

Ski & Snowboard Registration Form

Participant Information

Sports Association Membership

Medical Update

Ski & Snowboard Information

Payment Information

Acknowledgment