Participant Information

Prefix: Dr. General Lt. Col. Miss Mr. Mrs. Ms. Mx. Participant First Name: Participant Last Name: Mailing Address: Address Line 2 City: State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico U.S. Minor Outlying Islands Virgin Islands Armed Forces Americas Armed Forces Europe, the Middle East, an Armed Forces Pacific Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Territory Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory Province (Foreign) Zip: - Zip Suffix Country: United States of America Canada Afghanistan Åland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia (Plurinational State of) Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cabo Verde Cambodia Cameroon Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo (the Democratic Republic of the) Cook Islands Costa Rica Côte d'Ivoire Croatia Cuba Curaçao Cyprus Czechia Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands [Malvinas] Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran (Islamic Republic of) Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea (the Democratic People's Republic of) Korea (the Republic of) Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia (the former Yugoslav Republic of) Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia (Federated States of) Moldova (the Republic of) Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestine, State of Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Réunion Romania Russian Federation Rwanda Saint Barthélemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syrian Arab Republic Taiwan (Province of China) Tajikistan Tanzania, United Republic of Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom of Great Britain and Northern Ireland United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela (Bolivarian Republic of) Viet Nam Virgin Islands (British) Virgin Islands (U.S.) Wallis and Futuna Western Sahara* Yemen Zambia Zimbabwe Phone: Home Mobile Other Work Phone: Home Mobile Other Work Email: Participant Gender: Female Male Participant Birth Date(MM/DD/YYYY): / / Parent/Guardian First Name Parent/Guardian Last Name Parent/Guardian Phone Number (Please format as 000-000-0000) Emergency Contact Name Emergency Contact Phone Number (Please format as 000-000-0000) Relationship to Participant Height Weight - in lbs Do you have a history of seizures? Yes No Seizure Type Petite Mal Grand Mal Other Have you had a seizure in the past 24 months? Yes No Has your seizure medication changed in the last 24 months? If yes, please explain: Do you have any allergies? Yes No Type of Allergies Do you carry an Epipen? Yes No Current Prescription Medications Side Effects of Medications Do you need assistance using the restroom? Yes No Autism Cancer Cognitive Subgroup Hearing Subgroup Medical Subgroup Neuromuscular Subgroup Orthopedic Subgroup Amputee Subgroup Vision Subgroup Other Which is your primary disability? Autism Cancer Cognitive Hearing Medical Neuromuscular Orthopedic Other Vision Not Applicable - I'm a caregiver Which is your secondary disability? Autism Cancer Cognitive Hearing Medical Neuromuscular Orthopedic Vision Other Not applicable Please describe how your disability affects you: Date of Injury (if applicable) Please indicate the activities that interest you Please rate your upper body strength Weak Average Strong Which side of your upper body is weaker? Left side Right side Neither Please rate your lower body strength Weak Average Strong Which side of your lower body is weaker? Left Right Neither Do you have normal muscle tone? Yes No If no, how would you describe your muscle tone? Spastic Athethoid Flaccid Other Are you ambulatory? Mobility What is your ability to transfer yourself? Transfers independently Transfers self w/assistance Can bear weight with assistance Cannot bear weight No ability to self-transfer Do you have sensitivity to hot or cold? If yes, please explain Do you have difficulty speaking or communicating? If yes, please explain. In addition, please let us know if you use a communication device or ASL Do you have difficulty with balance? If yes, please explain Do you have any shunts? If yes, where? Do you have any rods? If yes, where? Please list any other medical conditions or concerns not mentioned above that is pertinent for us to know List any social/behavioral/emotional issues we should be aware of and how we can assist Were you in the military? Was your injury post 2001? Have you been barred from receiving VA benefits? In what branch did you serve? What was your rank when you retired? In what wars/conflicts have you served? Date of Injury Was it service related? Yes No In what country/place did your injury occur? What VA Hospital are you connected with? VA Contact Name VA Contact Number I acknowledge the information provided in this form is true and correct to the best of my knowledge. I acknowledge that STARS cannot assist with the personal care of participants. I acknowledge that due to the equipment manufacturer determined weight limits and the personal safety of both the participant and instructor, STARS cannot accommodate sit skiers over 200lbs. I acknowledge STARS cannot administer medications. How did you hear about STARS? Google Search Social Media Web Ad Word of Mouth Other Name of Individual who completed form Relationship to Participant I am the participant Parent/Caregiver Sibling Spouse Other Date form was completed Create a Login Name: Password: Retype Password: Captcha