Therapeutic Adventures - Registration

P.O. Box 4668, Charlottesville, VA 22905 1-434-981-5834

Serving all your adaptive outdoor adventure needs!

On-line Registration

Name of Client:

Client Age:

Name of Parent(s) if Client is under 18:

Group Coordinator:

Agency / Organization:

Address 1:

Address 2:

City / County:

State:

Zip Code:

Email Address:

Day Phone:
(area code)number

Evening Phone:
(area code)number

Fax Number:
(area code)number

Type of Disability:
(example - spinal cord injury, cerebral palsy, etc.)

Type of Chronic Medical Diagnosis or Special Health Needs:
(example - spinal cord injury, cerebral palsy, etc.)

Additional Information:
(example - T5 paraplegia, ataxia, etc.)

Client's Primary Type of Mobility:
(check all that apply)

Ambulatory (walks):
Wears orthotic(s)/brace(s):
Uses crutches:
Uses cane(s):
Uses walker:
Wheelchair:
Manual:
Electric:

Adaptive Programs

Planning Your Learning Experience

Phase I - These are introductory courses for people who have had little or no experience with a particular activity. They lay the foundation for all our other courses.

Phase II - These courses reinforce and build upon the basics presented in Phase I. The many new skills introduced at this level are developed through practice in a variety of settings. Emphasis is placed on becoming more proficient movement and technical skills.

Phase III - These advanced courses are for people who have a solid grasp of Phase II skills. Emphasizing specific aspects of an activity, these courses will help you to develop the highest level of proficiency and technical skill in Adaptive Snow Sports.

Type of Instruction Preferred:
(check all that apply)

Private (1 person):
Semi-Private (2-3 persons):
Group (4+ persons):

Length & Time of Session Preferrred:
(check all that apply)

1/2 day - AM:
1/2 day - PM:
Full Day:
Night (5pm - 10pm):
Multi-Day:
Dates:

Adaptive Snow Sports:
(click option for details)

Alpine:	2-track 3-track 4-track sit-ski mono-ski bi-ski guiding

Snow Boarding:

Nordic:	telemark touring

Snow Shoeing:

MASS Porgrams & Services:
(click program for details)

Tiny Tracker:
Senior Skier:
Adapt-A-PALS:
Shared Adventures:
FAST - Frequent Adaptive Skier Tickets:
Independent Tracker:
Video Analysis:

Adaptive Water Sports:

Canoeing:

Fly Fishing:

Kayaking:	whitewater touring

Rafting:

Sailing:

Adaptive Wilderness Sports:

Backpacking:

Camping:

Mountain Biking:

Rock Climbing:

Adventure Challenge: (ropes)

Team Building:

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