Name
*
First Name
Last Name
Email Address
*
Phone
*
(###)
###
####
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Height
*
Weight
*
Shoe/Boot Size
*
Military Status
*
Active Duty
Veteran
Branch of Service
*
Army
Navy
Marine Corps
Air Force
Other
Military Rank
*
Conflicts Served/Dates Served
*
Describe Your Disability (Use as much detail as possible)
*
Country in which injury occurred
*
Iraq
Afghanistan
Other
Your Date of Birth
MM
DD
YYYY
Snow Sport
*
Skiing
Snowboard
Experience in this Snow Sport?
*
Yes
No
Rate Your Selected Snow Sport Ability: 0=Never Ever; 10=Expert
*
1
2
3
4
5
6
7
8
9
10
Preferred Terrain
Green
Blue
Black
Moguls/Terrain
If Applicable, List Ski or Snowboard Size, Ski or Snowboard Boot Size, Regular or Goofy Snowboard Binding
What Adaptive Equipment Do You Use?
Will You Bring Your Own Equipment?
*
Yes
No
If "No" Check All Equipment You'd like Us to Supply
Do You Have Any of the Following?
If You Selected Any of the Above, Describe the Severity and List Any Stressors to Avoid
Are You Able To Walk Independently?
Yes
No
If Yes, To What Percentage of the Day?
100%
75%
50%
25%
Less Than 25%
If No, List Any Mobility Assistance Devices You Use and Whether You Need Assistance With Transfers
Do You Have a Visual or Hearing Impairment?
Yes
No
If Yes, Indicate Any Devices You Use and the Level of Impairment
Do You Wear Any Spinal Stabilization Device?
Yes
No
If Yes, Describe the Device
Due to Your Injury, Do You Have Either of the Following?
If You Selected Either of the Above, Describe in Detail
Please List Any Prescription Medications You Take Regularly, and Common Side Effects, if Applicable
List Any Medals, Awards, or Citations You Have Received
We Receive Regular Media Requests for the Coverage of This Event. Would You Be Willing to Be Interviewed and Photographed?
Yes, I'm OK with the media.
No, I'd prefer no press coverage.
Guest Name 1
First Name
Last Name
Guest 1 Date of Birth
MM
DD
YYYY
Guest 1 Gender
Male
Female
If Guest 1 is Skiing or Snowboarding, Tell Us Which and List Height, Weight, Inseam, Shoe Size, and Jacket Size
Guest 2 Name
First Name
Last Name
Guest 2 Date of Birth
MM
DD
YYYY
Guest 2 Gender
Male
Female
If Guest 2 is Skiing or Snowboarding, Tell Us Which and List Height, Weight, Inseam, Shoe Size, and Jacket Size
Guest 3 Name
First Name
Last Name
Guest 3 Date of Birth
MM
DD
YYYY
Guest 3 Gender
Male
Female
If Guest 3 is Skiing or Snowboarding, Tell Us Which and List Height, Weight, Inseam, Shoe Size, and Jacket Size
Guest 4 Name
First Name
Last Name
Guest 4 Date of Birth
MM
DD
YYYY
Guest 4 Gender
Male
Female
If Guest 4 is Skiing or Snowboarding, Tell Us Which and List Height, Weight, Inseam, Shoe Size, and Jacket Size
Guest 5 Name
First Name
Last Name
Guest 5 Date of Birth
MM
DD
YYYY
Guest 5 Gender
Male
Female
If Guest 5 is Skiing or Snowboarding, Tell Us Which and List Height, Weight, Inseam, Shoe Size, and Jacket Size
