ES Adaptive Client Participation Form

Demographic Details

* Name (As it appears in your passport if we are organising your holiday)

* Date of birth

* Address

* Daytime telephone

* Evening telephone

* Email

Occupation

* Next of kin (and relationship)

* Next of kin contact details

* Height

* Weight

General physical condition

Other activities and sports involvement

Passport Details (only needed if we are organising your holiday)

Do you hold a British passport?

Yes

No

If no, which country do you hold a passport for? (Do you require a visa?)

Nationality

Passport number

Place of issue

Date of issue

Expiry date

Resort Details

* Accommodation

* Dates of stay

* Your contact details while in resort

Party leader name

Party leader contact details

How many others are in your holiday party?

Do they require ski/board lessons?

Yes

No

* Please note: If you are bringing carer/s and they would like to ski/board with you please can you ensure that they are competent red run skiers/boarders. If not, it is strongly recommended that they have lessons with European Snowsport in order to do this. Also, please be aware that if you are to be in a sit ski we will require an additional helper/carer to ski with us. We can help provide this and will contact you shortly if necessary.

Would you like European Snowsport to provide these lessons?

May I contact you to arrange these lessons?

Your Disability

* What is the diagnosis of your disability?

* How does this affect you physically?

* Do you have any sensory impairments?

Was your disability caused by an accident?

Yes

No

Date of accident (if applicable)

How does your disability affect your behaviour?

Communication skills

Frustration tolerance

Confusion

Attention span

Distractibility

Impulsivity

Anxiety

Following directions

Sequencing

Problem solving

Slow processing of information

Temper

Any additional comments?

If you have a learning disability, have you been assessed for a special educational needs assessment? Please state your needs.

Adaptive Ski Lessons

* Dates of requested ski lessons

* Times of requested ski lessons

Preferred meeting point

What do you wish to achieve from your skiing experience?

Mobility Needs

Please check all that you use

How far can you travel alone with your mobility aid?

Can you manage stairs both up and down?

Yes

No

Can you transfer to a chair/bed/toilet without specialist equipment?

Yes

No

If you need assistance, how much help do you need and what equipment do you require?

What equipment if any do you require at home?

Do you require any orthosis/prosthesis?

Yes

No

Please state the purpose of the orthosis

Do you have any history of pressure sores? Please state where, grade and if still present

Care Needs

Do you have carers at home?

Yes

No

How many carers do you require?

Please indicate how much help is required for the following activities of daily living:

Washing

Dressing

Eating

Toileting

Managing money

Shopping

Administering medication

Other: please specify

Do you have any episodes of urinary incontinence?

Yes

No

Do you have any episodes of faecal incontinence?

Yes

No

If yes, how often do you need help?

Do you have any problems with the following (please give details)

Vision

Hearing

Speech

General Information

Do you have any special dietary requirements?

Please give details

Is this your first skiing experience?

Health

Have you been given any precautions from injuries/surgery?

Do you have any other medical conditions?

Do you have sensitivity to the cold/heat/sun?

Do you fatigue quickly?

Do you have a respiratory condition?

Do you have a cardiovascular condition?

Do you have a history of seizures? (Please state type, duration, frequency and date of last seizure)

Adaptive Equipment

European Snowsport Adaptive Ski School will provide you with the adaptive equipment but boots and skis for stand-up skiers need to be hired. An instructor will attend the hire shop with you and assist in equipment set-up within the shop.

Please note that a ski helmet is compulsory for all Adaptive lessons and that you will be required to wear a one, you can bring your own or hire a one in resort.

Will you be bringing any of your own equipment? If so, please state what you intend to bring with you.

Do you have any problems with your feet or require insoles? Please advise so we can ensure comfortable fitting ski boots

Please state equipment used and size (if known)

Ski boot/s size: left and right

If you have been skiing before?

Did you use outriggers?

Yes

No

If so, do you know which size?

Which ski school/association do you/did you attend?

Has your disability fluctuated since your last skiing trip?

Consent for Publicity and Photos

* I hereby authorise and give full consent for European Snowsport Adaptive School to copyright or publish all photographs, videotapes and films in which I appear whilst participating in lessons. I further agree that European Snowsport Adaptive school may transfer, use, or cause to be used, these photographs, videotapes or films for any exhibitions, publications, public displays, publication commercials, art and advertising purposes without limitation or reservation.

I agree

Applicant/Next of Kin

* I have completed and understood all parts of this form

Signed/Name

* Please check as appropriate

* Date

Please note, all the information given on this form will be given to the instructor and helper (if a helper is required). This is for your safety and wellbeing. You will be notified if a helper is required.

It is imperative that the information you have given us is correct. We reserve the right to cancel lessons if the information you have given us is misleading.

Data collection
We would like to keep you informed about fundraising events, news and developments of ES Adaptive. Please advise us if you would prefer not to be contacted

Please do not contact me

Thank you. We look forward to skiing with you soon!

* Indicates Response Required