2018 ASA Athlete Application Form
Athlete Personal Information
Athlete's First Name
Athlete's Last Name
Athlete's Birth Date
Athlete's Gender
Male
Female
Which of the following best represents the Athlete's racial or ethnic heritage?
Please select...
Non-Hispanic White or Euro-American
Black, Afro-Caribbean, or African American
Latino or Hispanic American
East Asian or Asian American
South Asian or Indian American
Middle Eastern or Arab American
Native American or Alaskan Native
Other
Athlete's Weight
Athlete's Height
Unisex T-Shirt Size
Small
Medium
Large
XL
Athlete Medical History
List the primary diagnosis/injury that resulted in your disability.
How long have you been living with your disability?
Wheel Chair Type
Manual operation
Electric mode of operation
None - if you do not use a wheelchair or other assisted mobility devices outside of the home, the WingMan Program is not the best fit for you. We focus on serving athletes with limited to no mobility.
What other Assisted Mobility Devices do you use outside of the home?
Cane
Crutches
Walker
Wheelchair Only
None - if you do not use any assisted mobility devices outside of the home, the WingMan Program is not the best fit for you - we focus on serving athletes with limited to no mobility.Edit this text
History of seizures?
Yes
No
If yes to the above question, how often do you have seizures, how long do they last, and is there anything that can be done to help you through the seizure?
Do you have special toileting needs? (Pre-race, on the course or post race - Do you need support using the restroom? If you are not continent, do you require special accommodation during a race?)
Can you take liquids orally? If so, do you have any special needs? ie Require straw, special cup, support holding a cup? Do you have any special hydration requirments during a race - how much, how often, etc?
Can you take in solids orally? If so, please answer this question and the following: do you have any special nutritional needs during a race? How often, how much, what size?
Do you have any food allergies or diet requirements we need to be aware of?
Are there additional medical/physical/behavioral issues we should be aware of?
How do you communicate? (Verbally? Device? Sign Language? Facial expressions/hand gestures?)
We're excited to get to know you, tell us more!
Please tell us a little about yourself? :) Family, activities, favorite things (movies, music, sports teams etc), other activities you're involved in.
Parent/Guardian or Emergency Contact Information
Parent/Guardian's First Name
Parent/Guardian's Last Name
Relationship to Athlete
Race Day Emergency Contact Name and Phone Number
Email Address
Email Address 2
Address 1
Address 2
City
State
Zip
Racing Training Information
Do you already have team members in mind to join you? (Relative or friend that would like to compete alongside you) If yes, please provide names and email addresses.
What ASA Community would you like to join?
Anne Arundel County
Baltimore City
Baltimore County
Eastern Shore
Frederick County
Harford County
Howard County
South Central PA
Other
What is the longest training or racing distance that you have completed?
5K
10K
10-miler
12-miler
Half marathon
Other
If other, please explain
How will you be arriving to training and/or races? (Please know that ASA does not provide transportation. ASA Captains & WingMen are not allowed to transport athletes.)
Family/Friend
Public Transportation
Day Program
Parent/Guardian Consent
Waiver - Adult Athlete or Parent/Guardian initials
By providing my initials below I acknowledge my understanding that my participation in any Athletes Serving Athletes event and/or any pre- or post-event activities (collectively, the “Event”) involves rigorous physical activity and that it potentially may be hazardous. I attest and verify that my ability to participate in the Event has been verified by a licensed medical doctor. I expressly assume all known and unknown risks associated with the Event, including but not limited to: loss of or damage to my property; injury (including death); accidents; the effects of weather; and terrain conditions that may vary widely, and that may include uneven and/or slippery surfaces, spectators, participants, and natural and man made obstacles (including without limitation, vehicles, security barriers, signs, cables, mats, and debris on the course). In consideration of my participation in the Event, I, for myself, my heirs, executors, administrators, personal representatives, successors and assigns, waive any and all rights, claims and causes of action I have or may have against any Race Organizer that may arise as a result of my participation in the Event. For these purposes, a “Race Organizer” is any one or more of the following: Athletes Serving Athletes and their affiliates; all governmental agencies representing the territory in which the Event will be held; all sponsors, agents, vendors, and contractors of or for the Event; medical service providers; and the officers, directors, employees, representatives, successors and assigns of each of the foregoing. I hereby agree to indemnify all Race Organizers for all claims and losses (including attorney’s fees and court costs), which may be brought against any one or more of them by anyone claiming to have been injured or otherwise to have suffered loss or damage as a result of my participation in the Event. I grant Athletes Serving Athletes permission to register me for races on my behalf. I further grant full permission to any and all of the foregoing to store, use and/or reproduce my image or likeness by any audio and/or visual recording technique (including electronic/digital) now in existence or hereafter invented, for any legitimate purpose, including commercial sales and marketing purposes. I understand and agree that information about me that is collected by Athletes Serving Athletes or the Race Organizers, including without limitation information on this form and my Event results may be disclosed to third parties for any legitimate purpose, including commercial sales and marketing purposes, and that it may be subject to re-disclosure by the recipient(s). I acknowledge and agree to abide by any Official Rules for the Event that may be posted at the Event or on the Event’s website. I hereby represent and warrant that I am 18 years of age or older or, if applicable, that I am the parent or legal guardian of the child under the age of 18 years old who I am registering for the Event and that I have the full power and authority to agree to these terms on behalf of such child, and to bind him/her to these terms.
Athlete Picture - upload current photo
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