Migrate Account Form

Contact Information

Participant First Name *

Participant Last Name *

Prefix

Address *

Address Line 2

City *

Territory

State/Province *

Zip Code *

Country

Phone *

Phone 2

Email *

Gender *

Please select the ethnicity/race that best describes the participant. *

Date of Birth *

*If the participant is under 18 or legally incapacitated, please complete the parent/guardian information below.

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian Phone Number (Please format as 000-000-0000)

Emergency Contact Information

Emergency Contact Name *

Emergency Contact Phone Number (Please format as 000-000-0000) *

Relationship to Participant *

Health History

Height *

Weight - in lbs *

Due to equipment manufacturer determined weight limits and the personal safety of both the participant and instructor, STARS cannot accommodate sit skiers over 200lbs. Please call STARS office at 970-870-1950 for more options.

Do you have a history of seizures? *

Seizure Type

Have you had a seizure in the past 24 months?

Has your seizure medication changed in the last 24 months?

Yes

No

If yes, please explain

Do you have any allergies? *

Type of Allergies

Do you carry an Epipen?

Current Prescription Medications

Side Effects of Medications

*Please note, STARS cannot administer any medication.

Do you need assistance using the restroom? *Please note, STARS cannot assist with the personal care of participants, such as toileting and changing. You must make arrangements prior to your lesson/camps if you need assistance with personal care concerns. *

*Please note, STARS cannot assist with the personal care of participants. You must make arrangements prior to your lesson/camps if you need assistance with personal care concerns.

Disability Information

Autism

Yes

Cancer

Yes

Cognitive Subgroup

Hearing Subgroup

Complete Loss - Left

Complete Loss - Right

Partial Loss - Left

Partial Loss - Right

Medical Subgroup

Achondroplasia

Agenesis of Corpus Callosum

Arthritis

Diabetes

Heart Defect

Usher Syndrome

Neuromuscular Subgroup

Orthopedic Subgroup

Amputee

Fused Joints

Growth

Scoliosis

Amputee Subgroup

L-AEA

L-BEA

L-AKA

L-BKA

R-AEA

R-BEA

R-AKA

R-BKA

Vision Subgroup

Complete Loss - Left

Complete Loss - Right

Partial Loss - Left

Partial Loss - Right

Other

Which is your primary disability? *

Which is your secondary disability? *

Please describe how your disability affects you *

Date of Injury (if applicable)

Activity Interests

Please indicate the activities that interest you

Strength and Range of Motion

Please rate your upper body strength *

Which side of your upper body is weaker? *

Please rate your lower body strength *

Which side of your lower body is weaker? *

Do you have normal muscle tone? *

If no, how would you describe your muscle tone?

Are you ambulatory? *

Yes

No

Mobility *

Walks independently

Walks with assistive device

Manual wheelchair

Power wheelchair

What is your ability to transfer yourself? *

Medical Information

Do you have sensitivity to hot or cold? *

Yes

No

If yes, please explain

Do you have difficulty speaking or communicating? *

Yes

No

If yes, please explain. In addition, please let us know if you use a communication device or ASL

Do you have difficulty with balance? *

Yes

No

If yes, please explain

Do you have any shunts? *

Yes

No

If yes, where?

Do you have any rods? *

Yes

No

If yes, where?

Please list any other medical conditions or concerns not mentioned above that is pertinent for us to know

List any social/behavioral/emotional issues we should be aware of and how we can assist

Military Information

We kindly ask that anyone attending a grant funded military program, to please complete this section. This information is important for us to stay compliant and receive military funding. Thank you.

Were you in the military? *

Yes

No

Was your injury post 2001?

Yes

No

Have you been barred from receiving VA benefits?

Yes

No

In what branch did you serve?

What was your rank when you retired?

In what wars/conflicts have you served?

Date of Injury

Was it service related?

In what country/place did your injury occur?

What VA Hospital are you connected with?

VA Contact Name

VA Contact Number

Acknowledgement

I acknowledge the information provided in this form is true and correct to the best of my knowledge. *

Yes

I acknowledge that STARS cannot assist with the personal care of participants. *

Yes

I acknowledge that due to the equipment manufacturer determined weight limits and the personal safety of both the participant and instructor, STARS cannot accommodate sit skiers over 200lbs. *

Yes

I acknowledge STARS cannot administer medications. *

Yes

How did you hear about STARS? *

Name of Individual who completed form *

Relationship to Participant *

Date form was completed *

Create an account to save your information and access our online portal!

You must create a username and password to appropriately complete your registration. You will then have the ability to update your paperwork online each time you want to participate with STARS.

(Your password must be at least eight characters long, and contain at least one number.)

Create a Login Name *

Password *

Retype Password

Data Privacy & Consent

Yes, I would like to receive communications from STARS by email.

Yes, I would like to receive communications from STARS by phone.

Yes, I would like to receive communications from STARS by mail.

Yes, I would like to receive communications from STARS by SMS.

STARS privacy policy states how we treat your personal data and protect your privacy when you use our Services. Based on your answers below, it will effect how STARS is able to communicate with you and provide information regarding programming, scheduling, and services we provide.

STARS Privacy Policy