Winter Student Registration

New or Returning *

New

Returning

(clear)

Please indicate if you are a new or a returning student.

Prefix

First Name *

Middle Name

Last Name *

Suffix

Birth Date *

(clear)

Gender

Female Male (clear)

Street Address *

City *

Postal Code *

Province

Phone (Home) *

Phone (Work)

Phone (Mobile)

Email *

Height *

Weight *

Our equipment allows for a maximum weight of 180 lbs (82 Kg).

Medication

Handicap General *

Amputation details

Vision details

B1 B2 B3 Other

Handicap Information

Season Schedule *

Please select the THREE (3) dates from either GROUP 1 or GROUP 2. Please DO NOT send in your cheque nor passport photos until you receive confirmation that there is a space available for you in your chosen group.

Comments: How did you hear about the organization?

Amputee	Cerebral palsy	Hearing
Hemiplegic	Intellectual	Paraplegic
Polio	Quadraplegic	Spina bifida
Other

Left leg	Under left knee	Left foot	Right leg
Under right knee	Right foot	Left arm	Left forearm
Left hand	Right arm	Right forearm	Right hand
Other

Dec_10_2011_CANCELLED	Dec_17_2011_Training
Jan_7_2012 _Training	Feb_11_2012_Training
Mar_3_2012_Instructor_Day	Jan_14_2012_Grp_1
Jan_28_2012_Grp_1	Feb_18_2012_Grp_1
Jan_21_2012_Grp_2	Feb_4_2012_Grp_2
Feb_25_2012_Grp_2	Soldier_On_Fest_February_6-9_2012

Adaptive Sports Foundation

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Adaptive Sports