Adaptive Sailing Form

Disability Type*

If "other" please provide more information:

Please describe the nature of your disability:*

Do you require the assistance of a hoyer lift for transference to the boat?*

Will your caretakers be able to assist with your transfer to the boat?*

Are you able to support your upper body independently?*

Any adaptive equipment used on land? (ie wheelchair, walker, etc):*

Participant Name*

First Last

Age*

Weight*

Height*

Address*

Street Address City State ZIP Code

Parent/Guardian Name (if applicable)

First Last

Phone

Email*

Emergency Contact Name*

First Last

Emergency Contact Phone*

Are you a military veteran?*

Do you require a handicap van parking space?*

Will you be having a guest or a care taker joining you out on the water?*

If so, please provide additional release forms for them as well.

Signature*

First Last

Please type your name to sign

Date*

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ADAPTIVE SAILING AUTHORIZATION FORM