SKI APACHE DISABLED SKIERS’ PROGRAM
P.O. BOX 2138
RUIDOSO, NM 88355

STUDENT ENROLLMENT APPLICATION

DATE_______________                  PLEASE PRINT CLEARLY                 

STUDENT’S NAME______________________________________________________
Phone #_____________________e-mail_______________________________________
Address_________________________________________________________________
City, State______________________________________________Zip______________
*Age_____Sex_____Height________Weight________Shoe size___________________
Parent/contact person___________________________________Phone#_____________

MEDICAL INFORMATION
 Description of Disability (include description of speech/language skills and behavioral considerations where applicable)_____________________________________________
________________________________________________________________________
Seizures: Yes_____No____*Date of Last Seizure_________Type__________________
Medications: Yes_____No_____Type_________________Affects__________________
  Note:  High altitude (Ski Apache base is 9600’) may alter the effects of medications 
Permanent conditions or medical apparatus we should be aware of (eg. Harrington Rods, shunts, catheters, etc.)_________________________________________________
________________________________________________________________________
If paralysis, where on spine:_________________________________________________
If head injury, explain______________________________________________________
________________________________________________________________________
Doctor/Therapist______________________________________ Phone#_____________

SKIER/SNOWBOARDER INFORMATION
(Never-ever)____(Skied before)_____Number of times?____Where?________________                           
Activities, sports, hobbies:__________________________________________________
_______________________________________________________________________
Boots_________________Skis/SB________________________Helmet_____________

INSTRUCTOR FEEDBACK
Instructor name___________________________________________________________
Adaptive equipment_______________________________________________________
Reminders_______________________________________________________________
Chairs?_____________________Additional comments on back:____________________

SAFETY FIRST!  
*Everyone 17 years of age and younger MUST wear a helmet
*If you have had a seizure within the past two years, you MUST wear a safety harness