Leisure Buddy Registration

Name *

Birthdate (yyyy/mm/dd) *

Please list primary location of services:

Squamish

Whistler

Pemberton

Address *

Province/Territory/State/Region *

Postal/Zip Code *

Mobile Phone *

Home Phone *

Email Address *

Program Information

Please select all areas of interest from the list below:

Please select all areas of interest from the list below: Other...

Photo Consent:

I consent for any photos taken of me during the Summer Sport Academy to be used for the Whistler Adaptive Sports Program website, social marketing pages, fundraising documents and proposals, media and other marketing uses:

Photo *

Yes

No

Medical Information

Disability:

Please list all medications and/or additional medical concerns

General Information

What are the participants favourite things?

What are they most interested in? We would like to be able to build meaningful relationships between participants and buddies, so this could be their favourite movie, sport, food, anything that can help us establish rapport!

How does the athlete best learn?

i.e visual learner, demonstration, repetition, etc.

What are the participants and caregivers goals for this program?

i.e. water safety, social skills, fun, etc.

What works best for the participant to achieve success?

How can we best set the participant up for success? i.e Strategies that are helpful, consistency, sensory concerns, length of programs, etc.

Additional helpful information

Please feel free to include any additional info that may be helpful for staff or volunteers to know to best accommodate the participant.

How imperative is having consistency in buddies from session to session? ie, same individual each time

1 - NOT imperative

5 - Indifferent

10 - VERY imperative

Please describe needs for consistency:

How imperative is having consistency in buddies from session to session? ie, same individual each time Please describe needs for consistency:

On a scale of 1-10, with 1 being NOT imperative, and 10 being VERY imperative.

Emergency Contact Person *

Relationship to that person *

Emergancy Contact Number 1 *

Emergency Contact Person 2

Emergancy Contact Number 2

How did you hear about us?

*The registration and confirmation process may take up to 72 hours to process. We greatly appreciate your patience and understanding.