Participant Registration FormBay Area Outreach & Recreation Program (BORP)

Participant Registration Form
Bay Area Outreach & Recreation Program (BORP)

I am completing this form for:

MyselfSomeone who is under age 18 or under legal conservatorship

ABOUT THE PARTICPIANT

Participant Type

Other Participant Type:

Participant First Name

Last Name

Birthdate

Phone

Gender

Address Line 1

City

State

Zip

County

PROGRAM

Adventure/OutingsArcheryClimbingCyclingFitnessGoalballKayakingPower SoccerSled HockeyWheelchair BasketballWheelchair Rugby

ETHNICITY

Hispanic/Latino(a) :

YesNo

RACE

Single Race Categories

Multiple Race Categories

Other Race

PARENT/GUARDIAN INFORMATION

Parent/Guardian Name

Parent/Guardian Address

Phone (hm)

Phone (wk/cell)

How did you first hear about BORP?

Other

HEALTH INFORMATION

Emergency Contact Person

Relationship to Participant

Phone

Do you have a disability

YesNo

Disability

Spinal Cord InjurySpina BifidaCerebral PalsyAmputeeStrokePost-PolioBlind/VisualTBIMultiple SclerosisMuscular DystrophyParkinson'sSeizure DisorderCystic FibrosisDwarfismAutism Spectrum DisorderOther

Other disability:

Do you Use Any Assistive Devices

YesNo

Please check any assistive devices used:

power wheelchairmanual wheelchairscooterwalkercaneservice animalprostheticsOther

Other assistive device:

Describe any other health conditions or information we should know in case of an emergency:

OTHER CHARACTERISTICS

Housing Circumstances

Household Size

Household Income

Currently enlisted in US Military

YesNo

US Veteran

YesNo

I HEREBY CERTIFY THAT THIS INFORMATION IS TRUE AND CORRECT

Date

Name of the Person Completing this Form

Relationship to Participant

Signature of the Person Completing the Form

Contact Information