Colorado Discover Ability · New Participant Registration (2023)

Contact Information

Participant's Name

*

First Name

Last Name

Phone

*

Address

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Email

*

Verify Email

*

Legal Guardian's Name (if Applicable)

First Name

Last Name

Legal Guardian's Phone Number

Legal Guardian Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Legal Guardian Email

Verify Email

Emergency Contact

Emergency Contact's Name

*

First Name

Last Name

Emergency Contact's Relationship to Participant

*

Emergency Contact Phone

*

Emergency Contact Email

*

Verify Email

*

Demographic Informatioin

CDA receives funding through grants and gifts from many organizations and individuals. That funding helps us keep costs low for the participant. Scholarships are available and based on many details of your life such as age, income, type of disability, etc. Please fill out this section as completely as possible.

Participant Date of Birth (Month/Date/Year)

*

(mm/dd/yyyy)

Participant Age:

*

Participant Height:

*

Participant Weight:

*

Participant Gender

*

Female

Male

Prefer not to say

Other

Participant's Ethnicity

*

Participant T-shirt Size

*

Is the Participant Employed?

*

Organization/Employer

Income

*

Please enter the yearly income for your household

Is the participant on Public Assistance?

*

Does the participant receive any of the following benefits? (Please select all that apply)

*

Social Security

SSDI

Medicaid

Medicare

Other

Not Applicable

Is Parent/Guardian/Caregiver Employed?

*

Select "Not Applicable" if you are the participant

Is the Parent/Guardian/Caregiver on Public Assistance?

*

Select "Not Applicable" if you are the participant

Does the Parent/Guardian/Caregiver receive any of the following benefits? (Please select all that apply)

*

Select "Not Applicable" if you are the participant

Social Security

SSDI

Medicaid

Medicare

Other

Not Applicable

Does the Participant or Parent/Guardian/Caregiver rent or own home?

*

Number of People in Household

*

Participant Information

This section is intended to provide our staff and volunteers with information to best accommodate the participant. It is vital that we have this information prior to the event. Please be as specific as possible.

Program(s) of Interest

*

Please select all programs that you are interested in participating in:

Cycling

River Floats/ Paddleboards

Youth Adventure Camp (ages 8-20)

Adult Adventure Camp (ages 21+)

Tennis

Sled Hockey

Alpine Skiing

Alpine Snowboarding

Scheduling as individual or group participant

Is the participant planning to participate with CDA as an individual or as part of a group:

*

Individual

Group

Group Affiliation (If participating in a group lesson or activity, please write in the: school name, VA program, Assisted Living Organization, or similar that the participant will be attending with)

Disability Services

Individuals receiving services through an HCBS Waiver or Family Support Services (FSS) may be able to utilize these services to bill for the cost of CDA activities. It is the participant's responsibility to pre-authorize this benefit with their caseworker.

Case Worker's Name (If Applicable)

First Name

Last Name

Case Worker's Organization

If the participant has a case worker, many times the case worker's organization will cover CDA participant costs and we will bill them directly.

Case Worker's Phone

Case Worker's Email

Verify Email

Direct Support - Will a Guardian/Caregiver be accompanying the Participant? (if yes, please have direct support individual complete all waivers).

*

Yes

No

Name of Direct Support Individual

First Name

Last Name

Medical Information

Please note that CDA does not administer medications.

*

I understand

Does the Participant have any allergies?

*

If you checked "yes" for allergies, please list them below.

Does the Participant need to carry medication?

*

Please note that CDA does not administer medications.

Yes

No

Does the participant carry an Epi Pen?

*

Yes

No

Many people with diabetes can be impacted by activity and by warm summer days. Is the participant diabetic?

*

Yes

No

Which statement is most accurate for the participant?

*

I am insulin dependent

I don't use insulin

Please list all your medications below. (We ask for this information in case of an emergency so that care can be received immediately from a medical professional.)

*

Does the Participant take any medication that may affect their participation in the events? Please list them.

We ask for this information in case of an emergency so that care can be received immediately and safely.

If you selected "other", please elaborate

Disability

By filling out this section as in depth as possible, CDA can provide the optimal experience and continue funding for programming.

Please describe the extent of the disability/disabilities.

*

If you selected "other" please elaborate.

Communication

Communication Needs

Only fill this section out if the Participant has communication preferences and/or barriers.

Non-Verbal

Non-English Speaking

Fluent Aphasia

Non-Fluent Aphasia

Uses an Interpreter

Uses American Sign Language (ASL)

Uses a Electronic Communication Device such as an AAC

Other

If you selected "other" please explain:

Mobility

Mobility Considerations

*

Please explain the Participant's range of mobility such as stamina, balance issues, limb range of motion, or anything else that may impact the Participant's ability to participate in activities.

Veterans

Only veterans need to fill out this section. If the Participant is not a Veteran, please skip to the next section.

Is the participant a Veteran?

*

Years served in the Military

Military Branch

Is the participant's disability service related?

Yes

No

Additional Information

This information helps CDA create a tailored experience for individuals.

How does the participant do in a group setting?

Is there anything else that would help us provide the best experience for the participant?

Examples: behavior management techniques, routines, normal behavior traits etc.?)

Media and Release of Liability Waivers

Please complete our release of Liability: (#1) and Media Waivers (#2). Participants cannot participate without a Release of Liability Waiver. These waivers must be completed yearly. The Media Release Waiver (#2), although optional, allows CDA to use photos on our media. To fill out these waivers, submit this form then head to our website www.cdagj.org. On the home page, place your cursor on the "Our Programs" tab. A drop down labeled "Forms" will appear. Click on this label. It will redirect you to our Forms webpage where you can select participation & media release waivers. Or you can copy and paste this URL: https://www.waiverfile.com/b/ColoradoDiscoverAbility/ChooseWaiver.aspx Please have these filled out at least 48 hours in advance of the activity you have signed up for.

Colorado Discover Ability's Limitations

Please note that Colorado Discover Ability provides emergency care only. Personal care is the responsibility of the Participant or Caregiver. This includes toileting and administering medications.

Transportation Considerations

At this time Colorado Discover Ability cannot provide transportation to and from activities or events.