CCSA Student Registration Form

PLEASE NOTE
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Skier Information

First Name Please provide your first name.		Last Name	Please provide your last name.
Primary Phone		Secondary Phone
Address	Please provide your address.	City	Please provide your city.
State	Please provide your state.	Zip	Please provide your zip code.
Parent / Guardian Name		Email	Please provide your email address. You entered an invalid email address.
Height	Please provide your height.	Weight	Please provide your weight.
Shoe Size		Shirt Size
Birthdate	Please specify your birthdate. You must enter a valid date (M/d/yyyy).
Tell us how you learned about CCSA

Emergency Contact Information

Name
Primary Phone		Secondary Phone

Program Preferences

Lesson Day/Time (Indicate choice by 1,2,3)

Must be 1,2, or 3 Must be 1,2, or 3 Must be 1,2, or 3 Must be 1,2, or 3 Must be 1,2, or 3 Must be 1,2, or 3

Tuesday 6-8p		Wednesday 6-8p		Thursday 6-8p
Sunday 1-3		Sunday 2-4		Sunday 3-5

If there is a volunteer instructor with whom you wish to ski, please note name here:

Will you need rental skis? (Please do not check if you will be using a sit ski (mono or bi)
Need Rentals?

Skier Disability

Developmental Disability	Vision Impairment	Hearing Impairment
Spinal Cord Injury	Orthopedic Impairment	Limb Amputation
Traumatic Brain Injury	Cerebral Palsy	Stroke
Other

Please describe disability in detail to assist staff in placement:

Adaptive Discipline:

Vision Impaired	2 Track	Arm Amputee	Mono-Ski
Hearing Impaired	3 Track	Developmentally Disabled	Bi-Ski
	4 Track

Is skier currently under doctor's care for any condition, please specify:
Are there any limitations on the skier's activities? Please describe:
Medical Precautions (Please describe):

Seizures:
If yes, is it controlled by medication?
Type:
Last seizure:

Allergies:
Is skier a HEPATITIS B or C carrier?
Does skier have Down'S Syndrome?
If skier has Down's Syndrome, verification of atlantoaxial dislocation is needed. A doctor's signature is required.
Special diet? If so explain:
Does skier need assistance with
Bathroom? If so, explain
Eating? If so, explain

Does the skier have any particular behaviors that staff should be aware of? If so, please describe.

Sit-Down Skiers

Will rolling sideways onto the shoulders cause pain or injury to the back or shoulders, or cause dizziness?	yes	no
Can the skier push the wheelchair independently?	yes	no
Within the past six months, has there been any injury to, or surgery on, the back, spinal cord, or hips?	yes	no
Does the skier wear a back brace?	yes	no
If yes, describe brace:
Do you have Harrington Rods?	yes	no
If so, then please specify the length of time you've had them:

As a student or parent would you be interested in working on a committee.
Equipment Fundraising Web Special Events Training Board Member Public Relations

2018 Rates

Click on the price below to pay via Paypal or by Credit Card

	6 Year Old Fee	7+ Year Old Fee
Weekday Series	40	155
Weekday Series with Rentals	90	225
Weekend Series	40	225
Weekend Series with Rentals	90	295

We only ski students six and above. Payment is required prior to the first lesson. You may pay by US Mail, online, or at the first lesson. We also have limited Scholarship Opportunities available. Please fill out a Scholarship Application if needed.