4010 Deans Bridge Rd ● Hephzibah, GA 30815 800-292-9335 ● 706-796-6301 ● 706-796-0362 Fax [email protected] Adaptive Sports & Recreation Assessment Name (Last, First, MI) Home Address  Member  Associate  Veteran  Caregiver/Family  Volunteer  Other Contact # Alt.# Email Gender Are you Rated by VA for Service How often do you participate in Sport or Shirt Size M F Connected Disability? Recreation Activities? Times S M L Yes No Daily Weekly Monthly Yearly XL 2X 3X Diagnosis/ Type of Injury Spinal Cord Injury (SCI) – Level ______Complete Incomplete Paraplegia Quadriplegia Multiple Sclerosis (MS) Traumatic Brain Injury (TBI) Amputee Right Arm AE BE Left Arm AE BE Right Leg AK BK Left Leg AK BK Other (Please Specify) ______Branch of Service Air Force Army Coast Guard Marine Corp Navy National Guard Other (Please Specify) ______

Summer Sports Have you ever attended the Have you ever attended the Valor Have you ever attended the Golden Wheelchair Games? Yes No Games? Yes No Age Games? Yes No Check any Sport of Interest (All that apply): Air Rife/Air Guns Quad Rudy Table Tennis Archery Pool – Nine Ball Track & Field Bocce Power lifting Triathlon Bowling Power Soccer Wheelchair Basketball Canoe/Kayaking Rowing Wheelchair Fencing Cycling/Handcycling Sailing Wheelchair Softball Equestrian Swimming Wheelchair Tennis Other (Please Specify) ______

Winter Sports Have you ever attended the Winter Sports Clinic? Yes No Check any Winter Sport of Interest (All that apply): Alpine Skiing Cross-Country Skiing Snowmobiling Biathlon Sled Hockey Wheelchair Curling Bobsled Other Recreational Activities Have you ever attended the Summer Have you ever attended the Tee Have you ever attended the Creative Sports Clinic? Yes No Tournament? Yes No Art Festival? Yes No Check any Sport of Interest (All that apply): Adaptive Cross-Fit Concerts Jet Skiing Rock Climbing Adaptive Golf Dragon Boat Racing Off-Road Cycling Scuba Diving Badminton Fishing Paddleboarding Shuffleboard Bingo Horseback Riding Plays Surfing Checker/Chess Horseshoes Pickleball Water Skiing College Sports Hunting Professional Sports Whitewater Rafting

Member’s Preference Please List favorite Sport or Activities you have participated: 1. 2. 3. 4. 5. Please List in the order of preference the Sport or Activities you would like to participate: 1. 2. 3. 4. 5. Please List in the order of preference the Sport Clinic or Activities you would like to Learn:

1. 2. 3. 4. 5. Signature Date