Athlete Information Form
Midwest Adaptive Sports
Please check all sports you anticipate participating in.
Basketball - Adults
Basketball - Youth
Softball - Adults
Softball - Youth
Football
Rugby
Tennis
Snow Sports
Water Sports
Other
Participant Information
New Participant
Returning Participant
Name
Nickname
Are you a part of a group? (does not apply to team sports)
Yes
No
Group Name
Group Contact Name
Group Contact Number
Participant's (or Family's) Email
(Your email will only be used for MAS purposes and not sold to a 3rd party)
Participant's Mailing Address
Cell Phone Number
Work Phone Number
Date of Birth
MM
/
DD
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YYYY
Height
Weight
Gender
Male
Female
Non-binary
Race/Ethnic Origin
Legal Guardian Information
Is the participant under the age of 18 or have a legal guardian?
Yes
No
Legal Guardian 1 Name
Legal Guardian 1 Relationship to Participant
Phone Number
Email
Same address as participant
Yes
No
Mailing Address
Legal Guardian 2 Name
Legal Guardian 2 Relationship to Participant
Phone Number
Email
Same address as participant
Yes
No
Mailing Address
Military History
Military Service
Active Duty
Veteran
Neither
Branch of Service
Army
Navy
Air Force
Marines
Coast Guard
Space Force
National Guard
None of the Above
Military Rank
Service-related Injury
Yes
No
Does Not Apply
Place (AO) of Injury
Pre/Post 2001 Injury
Injured Pre 2001
Injured Post 2001
Does Not Apply
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Athlete Information Form
Emergency Contact Information
Name
Relationship to Participant
Phone Number
Type
Cell
Home
Work
Primary Healthcare Facility
Primary Physician's Name
Phone Number
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Athlete Information Form
ABILITIES
PLEASE Check ALL that apply to the participant. Provide specific information where requested. All information is voluntary and requested only to assist staff and instructors in providing quality service.
Date of Onset of Disability
MM
/
DD
/
YYYY
Gunshot victim (for grant purposes only)
Yes
No
PHYSICAL
Amputee
Arthritis
Arthrogryposis
Asthma
Cerebral Palsy
Congenital Heart Disease
Cystic Fibrosis
Diabetes
Hearing Impaired/Deaf
Heart Problems
Joint Injury
Multiple Sclerosis
Muscular Dystrophy
Nerve Damage
Post Polio
Respiratory Disease
Spina Bifida
Spinal Cord Injury
Stroke
Traumatic Brain Injury
Visually Impaired/Blind
Other
SEIZURES
Yes
No
MOBILITY
Independent Ambulator
Independent Ambulator with AFOs
Prosthetic
Canes/Crutches/Walker
Manual Wheelchair
Electric Wheelchair
MEDICAL
Colostomy Bag
Feeding Tube
Shunt
Tracheostomy Tube
Other
MEDICATIONS
Yes
No
LATEX PRECAUTIONS
Yes
No
ALLERGIES
Yes
No
DEVELOPMENTAL DISABILITY
Mild
Moderate
Severe/Profound
Autism
Down Syndrome
Other
LEARNING DISABILITY
Attention Deficit Disorder
Hyperactivity
Distractibility
Dyslexia
Perceptual Difficulty
Other
EMOTIONAL DISORDER
Anti-Social
Anxiety
Depression
Disorientation
Eating Disorder
Neurosis
Post Traumatic Stress Disorder (PTSD)
Psychosis
Schizophrenia
Substance Abuse
Other
BEHAVIOR
Acting Out
Aggressive
Self-Abusive
Other
How does the participant behave when upset or frustrated?
Explain any other behaviors that staff should be aware of and how the participant behaves when frustrated or upset.
COMMUNICATION
Verbal
Nonverbal
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Athlete Information Form
Recreation, Leisure, and Learning Information
Which of the following barriers restrict physical activity? Check ALL that apply.
Lack of Coordination
Lack of Endurance
Lack of Flexibility
Lack of Mobility
Lack of Strength
Other
What methods that would make learning easier? Check ALL that apply.
Tactile
Verbal
Visual
Other
Which human domain is the participant hoping to develop the most at Midwest Adaptive Sports? Number 1-5 with 1 being the most important and 5 being the least important.
1
2
3
4
5
Cognitive
Emotional
Physical
Social
Spiritual
What expectations as a participant do you have of your Midwest Adaptive Sports experience?
Please write a personal goal that can be achieved through participation at Midwest Adaptive Sports.
Do you have any additional information that would be helpful for the Midwest Adaptive Sports staff to be aware of?
Verification
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