Programs/About

Summer Registration for
Wintergreen Adaptive Sports

Please note: Student participation in Wintergreen Adaptive Sports is subject to review and evaluation by the WAS staff. The information contained on applications may be used internally by WAS staff and your volunteer instructors.

Click the Submit button at the end of this form once you have completed the application to send this form quickly and easily over the internet to Wintergreen Adaptive Sports.

Registration Form questions marked by * are required

• Register for the Winter programs here.

• Looking to register for our annual Wounded Warrior Weekend? Go here.

• The Every Day is Armed Services Day for Wounded Warrior program details are here.

Welcome! Questions? Call us at 434-325-2007

Who is completing this form for the student? *

I am the person taking lessons.

I am a parent, guardian, etc., of the student.

Have you (the student) taken a lesson with WAS before? *

Student Name *

First Name

Last Name

Contact Email Address *

This will be the primary way WAS contacts the student.

Street or PO Box of student

What the Postal Service uses for mail

Town or City

State

Two letters, (VA for Virginia, for example)

ZIP code

Landline Contact Phone

(###)

###

####

Mobile Contact Phone

(###)

###

####

Student Birth Date

YYYY

Disability Diagnosis or Injury *

Date of Diagnosis or Injury *

YYYY

Height

Weight

Father or Guardian Name (if minor applicant)

First Name

Last Name

Mother or Guardian Name (if minor applicant)

First Name

Last Name

Employer

Student, Parent, or Guardian Employer

Occupation

Student, Parent, or Guardian Occupation

Business Telephone

(###)

###

####

Emergency Contact

Emergency Contact Name

First Name

Last Name

Relation to Student

Emergency Contact Phone

(###)

###

####

Past Surgeries

Medications

Please include dosage, frequency, and reason prescribed

Other Pertinent Information

Where applicable, (i.e., medical equipment or prosthesis, bowel and bladder management, seizures, hearing impairment, visual impairment, sensory loss, other):

Physician Name

First Name

Last Name

Physician Phone

(###)

###

####

Physician Specialty

Are You Currently receiving Therapy Services?

Check all that apply

Physical Therapy

Speech Therapy

Occupational Therapy

Therapist Name

First Name

Last Name

Therapist's Address

Day(s) of Week You Are Interested in Taking a Paddling Lesson

All lessons are by appointment only and will be confirmed by phone

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Specific Dates on Which You Are interested in Taking a Paddling Lesson

List all prospective dates

Additional Comments

Please share any additional information that may assist our instructors in planning for your lesson (i.e. overall health, level of independence, etc.)

Sports and Activities

List all sports and activities in which you participate

Student Swimming Ability

Please describe in detail

Student Paddling Ability

Please describe in detail

Communication and Behavior Survey

For snow sports and paddling programs, but required only for students who need communication and/or behavioral accommodations

Communication Level

How Does the Student Communicate?

Verbally

ASL

Pictures

Augmentative Communication Device

Other Assistive Technology

Rank Sensitivity to Noise

1 = Not sensitive; 5 = Very sensitive

Rank Sensitivity to Cold

1 = Not sensitive; 5 = Very sensitive

Rank Sensitivity to Crowds

1 = Not sensitive; 5 = Very sensitive

Rank Sensitivity to Wearing Any of the Following: Jacket, Layers, Boots, Helmet, Goggles, Gloves

1 = Not sensitive; 5 = Very sensitive

Student Can Follow One-step Directions?

Student Can Follow Multi-step Directions?

Student Requires Visual Cues to Understand Directions?

Describe Any Special Communication Techniques Student Uses for Customary Requests

Expressing hunger or thirst, or need for a break, for example

Select the Student's Preferred Mode of Learning

Describe Any Incentives or Rewards Used to promote Student's Learning or Behavior

Plan to bring any objects or things connected to these when the student is scheduled for a lesson

Additional Comments or Suggestions to Facilitate the Student's Lesson?

Someone from Wintergreen Adaptive Sports will be in touch soon. Start looking at your calendar to plan your lessons. Check out our "How to take a lesson" here.

Questions? Call us at 434-325-2007. Thank you!

About the Summer programs

The Wintergreen Adaptive Sports summer paddling program teaches canoeing and kayaking to people of all ages and with all types of disabilities, cognitive and physical.

We have canoes and kayaks that are one-person (solo) or two-person (tandem). Typically at least one instructor and one assistant works with each student to adapt the boat, get comfortable on the water, and teach paddling strokes and skills. Learn more here

Wintergreen Adaptive Sports provides outdoor sports and recreational opportunities for persons with disabilities. We serve people of all ages and with all types of disabilities.

WAS offers adaptive instruction in alpine skiing, snowboarding, kayaking, and canoeing. Each summer at its Wounded Warriors Golf tournament, WAS holds an adaptive golf clinic.

Safety, fun, and learning are the priorities in every activity.