Who is completing this form for the student? *

I am the person taking lessons.

I am a parent, guardian, etc., of the student.

Student Name *

First Name

Last Name

Contact Phone # *

(###)

###

####

Student Birth Date *

MM

DD

YYYY

Date of Diagnosis or Injury *

MM

DD

YYYY

Father or Guardian Name (if minor applicant)

First Name

Last Name

Mother or Guardian Name (if minor applicant)

First Name

Last Name

Emergency Contact Name *

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

Has the student experienced a seizure in the past 365 days? *

If so, they will be required to wear a seizure belt for chairlift safety

Yes

No

Are You Currently receiving Therapy Services?

Check all that apply

Physical Therapy

Speech Therapy

Occupational Therapy

Day(s) of Week You Are Interested in Taking a Snow Sports Lesson *

All lessons are by appointment only and will be confirmed by phone

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

How Does the Student Communicate?

Verbally

ASL

Pictures

Augmentative Communication Device

Other Assistive Technology