ASPNC, PO Box 304, Franconia, NH 03580 603-823-5232 info@adaptivesportspartners.org

New Participant Form

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Active Duty
Retired
Veteran
Reserves
National Guard
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Medical Information

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Left Arm
Right Arm
Left Leg
Right Leg
NA
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Left Side Weak
Right Side Weak
Lower Body Weak
Upper Body Weak
NA
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Limited Left Side
Limited Right Side
Below Ankles
Below Knees
Below Waist
Below Chest
On Left Side
On Right Side
NA
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Hearing Aid
Left Side Impaired
Right Side Impaired
Total Loss
Implants
NA
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Left eye blind
Right eye blind
Peripheral Blindness
Shadows Only
Tunnel Vision
Total Blindness
Wears Glasses
Wears Contacts
NA
Shunt
Spinal Structural Device
Prescribed Exercise Program
Breathing Problems
Receives Occupational Therapy
Receives Physical Therapy
Bag
Diaper
Internal
Catheter

Communication

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No
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Strong expressive language ability
Limited expressive language ability
Diminished expressive language ability when stressed, frustrated or other
Needs processing time prior to responding
Expressive language is clear and audible
Expressive language is best understood only by those familiar with
Articulation and speech patterns
Non Verbal
Strong
Limited

Behavior

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Yes
No

1. A copy of the student’s behavior plan to keep on file.

2. Parents/guardians/caregivers give use of or provide (especially if food related) during the activity any reward or motivating item(s).

3. Parents/guardians/caregivers give use of or provide during the activity any specialized tools, i.e. a transition item, needed to implement the behavior plan.

Activities with ASPNC

* Adaptive Climbing
Alpine Skiing
Basketball
Biking
Boccia (Indoor)
Bocce (Outdoors)
Fitness Training
Floor Hockey
Garden Buddies
Golf
Hiking
Kayaking
Nordic Skiing
Power Soccer
Sled Hockey
Snowboarding
Snowshoeing
Softball
Swim
Tennis (Standup)
Tennis (Wheelchair)
Winter Hiking
Yoga

Please download the Consent to Treat form, the Liability and Media Waiver, and the Parent & Athlete Concussion form and email, fax or mail to the office to complete your application.  We will call you to go over the other medical information you previously provided to us so we can update our records.

ASPNC is a Paralympic Sports Club. As such, we are required to provide data about participants to the US Paralympics organizations. This information is for non-commercial use and is kept confidential.

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Enriching the quality of life for people with disabilities
through year-round opportunities for sport, recreation and wellness.

www.AdaptiveSportsPartners.org