ASA Athlete Application
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 Height
Athlete's Weight
Unisex T-Shirt Size
XSmall
Small
Medium
Large
X-Large
XX-Large
Gender Specific Shirt Size
Women's XSmall
Women's Small
Women's Medium
Women's Large
Women's XL
Men's Small
Men's Medium
Men's Large
Men's XL
Men's XXL
Parent/Guardian's First Name
Parent/Guardian's Last Name
Relationship to Athlete
Primary Phone Number - This is the phone number that will be used for all office communications, and emergencies
Secondary Phone Number
Primary Email Address This is the email address that all office communications, agreements, information will be sent to
Secondary Email Address
Address 1
Address 2
City
State
Zip Code
What is your preferred method of contact?
Email
Phone Call
Text
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.
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? ASA does not provide toileting assistance
Can you take liquids orally? If so, do you have any special needs? Is Require straw, special cup, support holding a cup? Do you have any special hydration requirements 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 that we need to be aware of?
Are there additional medical/physical/behavioral issues that 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.
Racing Training Information
Do you already have team members in mind to join you? (Relative or friend who would like to run with you) If yes, please provide names and email addresses.
What ASA Community would you like to join? This is where you would like to attend Group Training Runs
Anne Arundel County
Baltimore City
Baltimore County Central - Towson
Baltimore County North - NCR Trail
Dauphin County, PA
Frederick County
Harford County
Howard County
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
Contact Information