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New Participant Information Form

✓Contact Info

✓Medical Info

✓Climbing + Fitness

Your Information

First Name*

Last Name*

Email Address*

Phone Number

Mailing Address*

Apt / Suite

City*

State*

Zip Code*

Date of Birth*

Gender*

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Medical Information

Do you have have clearance from a doctor to participate?*

Yes No

Are you a disabled veteran or disabled member of the armed forces?*

Yes No

Height:*

Weight (lbs):*

Disability Category*

Upper Limb Difference / Amputation Lower Limb Difference / Amputation Spinal Cord Injury Paralysis Visual Impairment / Blindness Hearing Impairment / Deaf Neurological Disorder Traumatic Brain Injury (TBI) PTSD Other N/A

Please give any other relevant details on your primary diagnosis, disability or special needs:*

Do you have any recent injuries or hospitalizations?*

Motor status: please list any concerns with muscle tone, range of motion and/or strength. Also note any spasticity or paralysis and affected area*

Do you use a mobility device?*

Please list any medications (dosage, frequency, reason for use)*

Relevant surgical procedure history (include dates)*

Do you have seizures?*

Yes No

Date and type of last seizure:

Any serious allergies requiring EpiPen or other medication?*

Please list any bladder or bowel adaptations*

Do you have a shunt?*

Yes No

Please indicate if any of the following that apply to you:

Diabetes*

Yes No

Poor circulation in limbs*

Yes No

Low endurance (tires easily)*

Yes No

Respiratory Problems*

Yes No

Severe Headaches or Migraines*

Yes No

High Blood Pressure*

Yes No

Low Blood Pressure*

Yes No

Memory Loss*

Yes No

Sensory Loss*

Yes No

Hearing Loss*

Yes No

Vision Loss*

Yes No

Communication difficulties*

Yes No

Anxiety*

Yes No

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Climbing and Fitness

Have you participated in a Paradox Sports event before?*

Yes No

Brief description of your current level of fitness:*

Please rate your climbing level:*

Please tell us more about your climbing experience:*

What are your goals for this event?*

Emergency Contact

Emergency Contact - Full Name*

Emergency Contact - Phone Number*

Emergency Contact - Relationship to you*

Submit

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Thank you!

Your submission has been received. If you have any questions, please contact us at:

Org Email or Org Phone