Adaptive Lesson Form - Bear Valley

Your Name*

First Last

Today's Date*

Lesson Date Request*

Lesson Time Request*

Student Name*

First Last

Student Height*

Student Weight*

Student Age*

Parent/Guardian Name (if applicable)

First Last

Students Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Emergency Contact Name*

First Last

Emergency Phone Number*

Email*

Please describe any specific needs

Medications*

Any Seizures in the last 12 months?*

If yes, please answer the question below.

Date of last Seizure

Does the Student use Adaptive Equipment?*

Please describe Equipment used

If answered OTHER to, "Do you use Special Equipment?" OR if you have any other specific equipment needs please describe here.

Students Hobbies, Sports or Recreation

Has the Student Skied/Boarded before?*

Please Describe any Ski/Snowboard Equipment Used in the Past

Additional Comments or Information