Adaptive Sports NW · Adaptive Sports Northwest Membership Registration

Membership Registration or Renewal Type

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Adult Athlete

Youth Athlete (under 18 years of age)

Non-Athlete

Personal Information

Tell us a bit about yourself.

Participant Name

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First Name

Last Name

Date of Birth

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(mm/dd/yyyy)

Gender

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Do you identify with the LGBTQ+ community?

Race and Ethnicity

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Native American, Indigenous, Alaska Native

Asian

Black or African American

Native Hawaiian or Pacific Islander

Latine or Hispanic

White or Caucasian

Prefer not to answer

Primary Language Spoken (if other than English)

Name of School or University, if attending

Have you served in the US Armed Forces?

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Yes

No

Do you have a disability?

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Yes

No

Prefer not to answer

Primary Disability

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U.S. Paralympic Designated Classifications

Are you ambulatory?

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Yes

No

Are you a current or former Paralympic and/or Team USA team member?

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Yes

No

National Team Highlights

Please share if you are willing. Example: Wheelchair Basketball Paralympic Team Member, Rio 2016, Gold Medal

Contact Information

How can we reach you?

Residential Address

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Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Mailing Address (if different from Residential)

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Primary Phone

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Alternate Phone

E-mail Address

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Verify Email

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Alternate E-mail Address

Verify Email

Parent/Guardian

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First Name

Last Name

Parent/Guardian

First Name

Last Name

Emergency Contact Info

Emergency Contact

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First Name

Last Name

Emergency Contact Phone

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Emergency Contact Relationship to Member

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Insurance Information

This is for emergencies only.

Current Insurance Carrier

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For example: Kaiser Permanente, Moda, etc

Name of Primary Policy Holder

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In the case of family policies, the athlete may be under another's insurance plan.

Policy ID Number

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Name of Primary Physician

First Name

Last Name

Physician Phone

Membership

Tell us how you want to be involved.

Where did you learn about us?

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Feel free to tell us more in the Additional Comments box below.

A friend, colleague, or family member

Google or other Search Engine

News Article

Event

Other

How many years have you been a member of ASNW?

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This is my 1st year

2 years

3 years

4 years

5 or more years

Current role within ASNW

i.e. Head Coach - Goalball; Board Member; etc.

T-Shirt / Polo Size

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Additional Comments

If you have any additional comments to make, such as expanding on any of your previous answers, please do so here.

General Waiver of Liability

To be completed by all members.

The link below will open a new tab with our General Waiver and Release of Liability Form in a PDF format for your review. Please read it in its entirety before continuing on with our Membership form.

ASNW General Waiver and Release of Liability Form (PDF)

You may also contact our Staff to request a paper copy at any time.

General Waiver & Release of Liability

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By checking this box, I am acknowledging that I have read the General Waiter and Release of Liability for ASNW participants and fully understand the terms and contents.

By filling in my name below, I accept the conditions and terms of the ASNW General Waiver & Release of Liability

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First Name

Last Name

FOR PARENTS/GUARDIANS OF MINORS: By filling in my name below, I accept the conditions and terms of the ASNW General Waiver & Release of Liability

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First Name

Last Name

Expectations & Code of Conduct

To be completed by all athletes.

The link below will open a new tab with our Athletes Code of Conduct form in a PDF format for your review. Please read it in its entirety before continuing on with our Membership form.

ASNW Athletes Code of Conduct Form (PDF)

You may also contact our Staff to request a paper copy at any time.

Expectations & Code of Conduct

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By checking this box, I am acknowledging that I have read the ASNW Athletes Code of Conduct and fully understand the terms and contents.

By filling in my name below, I accept the conditions and terms of the ASNW Athlete Code of Conduct

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First Name

Last Name

FOR PARENTS/GUARDIANS OF MINORS: By filling in my name below, I accept the conditions and terms of the ASNW Athlete Code of Conduct

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First Name

Last Name

Payment Options

Membership Cost

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$100 - Adult Athletes

$75 - Youth Athletes

$50

$25

$

Additional Payment for Membership

If you cannot make the full payment for your membership level at this time, please indicate how you would like to make up the difference (you can select multiple answers). A member of our team will be in touch to discuss options and next steps.

I would like to apply for a scholarship or grant, if available.

I am willing and able to complete volunteer service hours.

I would like to make partial payments or another financial donation later in the year.

Please contact me about options for payment to cover the remaining balance of my membership.

Whoo-hoo you made it to the end of the ASNW Membership Form!! Thank you taking the time to fill out this very important form; we appreciate you greatly.

The Submit button below will take you to the Payment Processing page where you can complete your Registration.

We can't wait to see you at the next event. Feel free to contact us at info@adaptivesportsnw.org if you have any questions.

Thank you!