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DSES Image

Student Information Form

Student Contact Information




























Emergency Contact Information



Military Service Information











                                          
                                          
Demographic Questions



Disability and Medical Information


Please describe: (include level of function or injury, describe cognitive issues, prosthetic, any implants, i.e. pins, spinal stabilizers, neck stabilizers, pace maker, hearing aids, shunts, orthotics etc.?)





Please describe: (include level of function or injury, describe cognitive issues, prosthetic, any implants, i.e. pins, spinal stabilizers, neck stabilizers, pace maker, hearing aids, shunts, orthotics etc.?)

Autism Spectrum Information






















TBI Information




PTSD Information






If yes, what percentage of the day?


















Disabled Sports Eastern Sierra has guidelines for safe participation. If it has been less than one year from the date of surgery please provide us with written permission from your Doctor to participate. Please fax documentation, or permission to participate, to 760‐934‐0729.




Seizure Information








Ski/Snowboard Experience










Please check all that apply



IMPORTANT INFORMATION: For the safety of the skier and instructor, the maximum capacity for a downhill sit ski is strictly 190 lbs. Sit skier may be weighed onsite to ensure they are within this limit. The maximum capacity for Nordic sit skiing is 220 lbs.
Summer Experience


Water Safety




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2019-2020 Liability Release and Assumption of Risk Agreement

I or my minor child or conservatee (collectively, “I”, “my”, or “me”) have voluntarily applied to participate in programs, related events, and activities of DISABLED SPORTS EASTERN SIERRA (the “Program”). I acknowledge that participation in the Program, including skiing, snowboarding, summer outdoor sports, any related winter and summer activities, and any use of the facilities associated with those activities are HAZARDOUS. I have made a voluntary choice to participate in the Program despite the inherent risks that it presents which include, but are not limited to, variations in terrain, snow conditions, weather conditions, visual perception, moguls, cliffs, rocks, forest growth, debris, man-made and natural objects, and other users of the facilities. I also agree that there may be other risks not known to me or not reasonably foreseeable at this time. In consideration of my participation in the Program, I agree to ASSUME ANY AND ALL RISKS OF INJURY OR DEATH associated with the Program, including all mountain transportation such as lifts.
I agree that prior to participating, I will inspect to the best of my abilities, or if a parent and/or legal guardian, I will instruct the minor participant to inspect to the best of his/her abilities, the facilities and equipment to be used. If I have any concerns about the equipment or facilities, I will immediately advise Disabled Sports of any such condition and refuse to participate.
Notice to MONO-SKI and BI-SKI SKIERS: To get up the ski hill, all skiers use a chair lift. As a sit-down skier, you will ride the chair lift in your mono-ski or bi-ski and will, with assistance, unload the lift by dropping down as much as three feet onto the unloading ramp. In this unloading process, your hips and back must be able to sustain the “jolt” or jarring that will occur. Falling is an inherent risk of skiing. In this case, your arms, shoulders, and back must be able to sustain the jolting or jarring that will occur. If you believe either unloading or tipping onto your side may cause you pain or injury, consult your doctor and discuss with Disabled Sports before attempting this activity.
In consideration for being permitted to participate in the Program, I AGREE TO RELEASE FROM ANY LEGAL LIABILITY AND AGREE NEVER TO SUE Disabled Sports Eastern Sierra, Mammoth Mountain Ski Area LLC, June Mountain Ski Area, the United States of America, Department of Agriculture, United States Forest Service, special event organizers, sponsors, and all of their successors, heirs, assigns, directors, officers, partners, investors, shareholders, members, agents, employees, owners, landowners, parent and subsidiary companies, and affiliated companies and ski areas (collectively herein, “Disabled Sports Eastern Sierra”) for injury or death resulting from my participation in the Program and/or from the use of the facilities of Mammoth Mountain, June Mountain, and/or Tamarack Cross Country Ski Center, including, but not limited to, the use of buildings and premises, chairlifts, equipment, instruction, special events, and search and/or rescue (hereafter collectively referred to as “Use of the Facilities”), regardless of the cause, including the alleged NEGLIGENCE, breach of warranty, implied liability, or any other legal theories of Disabled Sports Eastern Sierra. I further AGREE TO DEFEND, INDEMNIFY AND HOLD HARMLESS Disabled Sports Eastern Sierra for any claims, lawsuits, damages, attorney fees, costs or judgments arising out of my participation in the Program and/or my Use of the Facilities.
I UNDERSTAND THIS IS A RELEASE OF LIABILITY THAT IS VALID FOREVER, and will apply whenever I participate in the Program. I understand that this RELEASE OF LIABILITY will prevent me, my minor child or conservatee, or my heirs and assigns from filing suit or making any claim for damages in the event of injury or death to myself or to any person or property which may result from my participation in the Program. Additionally, in the event I file or my minor child or conservatee or any legal representative files a claim or a lawsuit arising out of my participation in the Program or my Use of the Facilities, I AGREE TO DEFEND, INDEMNIFY AND HOLD HARMLESS Disabled Sports Eastern Sierra for any damages, attorney’s fees, or costs arising out of such a claim or a lawsuit. With a full understanding of this agreement, I nevertheless enter into this agreement freely and voluntarily and agree that it is binding upon me, my minor child or conservatee, my heirs, assigns and legal representatives.
I hereby authorize Disabled Sports Eastern Sierra and Mammoth Mountain Ski Area to copyright, use, or reproduce my image and/or likeness in photographs, video tapes and films in which I, the undersigned, or the minor participant, appear while enrolled in any of their programs for any purpose, without compensation or restriction and without incurring any debts or liabilities to me of any kind.
I understand that by signing this Agreement, I agree to be legally bound by its terms, which limits my legal rights and supersedes any other agreement or representations by or between the parties hereto. I understand and agree that this agreement is severable and that if any clause is found to be invalid, the offending clause will be stricken and the balance of the contract will remain in effect and will be valid and enforceable. This contract is intended to provide a comprehensive release of liability, but is not intended to assert any claims or defenses which are prohibited by law. I agree that any action will be brought in the County of Mono, State of California. Any disputes will be subject to and determined under the laws of the State of California.