Student Registration for Wintergreen Adaptive Sports

Please note: Student participation in Wintergreen Adaptive Sports is subject to review and evaluation by the WAS staff. The information contained on applications may be used internally by WAS staff and your volunteer instructors.

Click the Submit button at the end of this form once you have completed the application to send this form quickly and easily over the internet to Wintergreen Adaptive Sports.

 

Welcome! Questions? Call us at 434-325-2007

Who is completing this form for the student? *
Student Name *
Student Name
What the Postal Service uses for mail
Two letters, (VA for Virginia, for example)
Landline Contact Phone
Landline Contact Phone
Mobile Contact Phone
Mobile Contact Phone
Student Birth Date
Student Birth Date
Date of Diagnosis or Injury *
Date of Diagnosis or Injury
Father or Guardian Name (if minor applicant)
Father or Guardian Name (if minor applicant)
Mother or Guardian Name (if minor applicant)
Mother or Guardian Name (if minor applicant)
Student, Parent, or Guardian Employer
Student, Parent, or Guardian Occupation
Business Telephone
Business Telephone
Emergency Contact
Emergency Contact Name
Emergency Contact Name
Emergency Contact Phone
Emergency Contact Phone
Please include dosage, frequency, and reason prescribed
Where applicable, (i.e., medical equipment or prosthesis, bowel and bladder management, seizures, hearing impairment, visual impairment, sensory loss, other):
Physician Name
Physician Name
Physician Phone
Physician Phone
Are You Currently receiving Therapy Services?
Check all that apply
Therapist Name
Therapist Name
Snow Sports Instruction Questions
Skip these if you are applying only for the summer adaptive paddling program
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
List all prospective dates
Please share any additional information that may assist our instructors in planning for your lesson (i.e. overall health, level of independence, etc.)
Additional Information for Mono-Skiing and Bi-Skiing Students
List all sports and activities in which you participate
Adaptive Paddling Sports Questions
Skip these if you are applying only for the winter adaptive snow sports program
Please describe in detail
Please describe in detail
Communication and Behavior Survey
For snow sports and paddling programs, but required only for students who need communication and/or behavioral accommodations
How Does the Student Communicate?
1 = Not sensitive; 5 = Very sensitive
1 = Not sensitive; 5 = Very sensitive
1 = Not sensitive; 5 = Very sensitive
1 = Not sensitive; 5 = Very sensitive
Expressing hunger or thirst, or need for a break, for example
Plan to bring any objects or things connected to these when the student is scheduled for a lesson

Get all your questions answered on How to Take a Lesson HERE

Wintergreen Adaptive Sports provides outdoor sports and recreational opportunities for persons with disabilities. We serve people of all ages and with all types of disabilities. 

WAS offers adaptive instruction in alpine skiing, snowboarding, kayaking, and canoeing. Each summer at its Wounded Warriors Golf tournament, WAS holds an adaptive golf clinic. 

Safety, fun, and learning are the priorities in every activity. 

TYPES OF SNOW SPORT LESSONS Offered BY WINTERGREEN ADAPTIVE SPORTS