Icebreaker Registration

Registration

Athlete's Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Phone Number*

Cell Number

Email*

Gender*

Date of Birth*

Ethnicity (for funding purposes only)*

School / Group Home

Is the athlete over the age of 18?*

Yes

Parent / Guardian / Caregiver #1

Parent #1 will receive a confirmation e-mail for this registration.

Parent / Guardian / Caregiver #1*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Employer

Employer Address

Street Address Address Line 2 City State ZIP Code

Phone Number*

Primary Email Address*

Parent / Guardian / Caregiver #2

First Last

Home Address (optional, if different)

Street Address Address Line 2 City State ZIP Code

Employer

Employer Address

Street Address Address Line 2 City State ZIP Code

Phone Number

Parent / Guardian / Caregiver 2 Email Address

Emergency Contact

Name*

First Last

Phone Number*

Athlete Diagnostic Info

Please supply any and all information that applies to your athlete.

How does your athlete communicate?

Speech

Sign Language

Non-Verbal

Other

If other, please explain:

Does your athlete wear AFO's?

Does your athlete have seizures?

If yes, how often do they occur?

How long do they last?

When did their most recent seizure occur?

Does your athlete have a shunt?

Does your athlete have any of the following conditions?

Autism/Spectrum Disorder

Cerebral Palsy

Hearing Impairment

Learning Disability

Down Syndrome

Intellectual Disability

Visual Impairment

Other disabilities not listed above

If yes, which of the following do they use:

Hearing Aid

Sign Language

Read Lips

Additional hearing impairment info:

Additional learning disability info:

Intellectual Disability

Does your athlete have any functional vision?

Other disabilities not listed above:

Does your athlete have any medical limitations or precautions?

If yes:

Other Info

Is your athlete eligible for reduced-fee lunches?

Permission

I hereby give my permission for my athlete to participate with SABAH in weekly therapeutic and recreational sessions as well as in SABAH’s Annual Celebration on Ice Show. The athlete may be photographed, videotaped or interviewed for the purpose of improving the quality of services provided by SABAH or for publicity purposes. It is the purpose of this agreement to exempt, waive and relieve releases from liability for personal injury, property damage, and wrongful death, including if caused by negligence, including the negligence, if any, of releases. “Releases” include SABAH Inc., event hosts, other participants, sponsors, advertisers, Board of Directors, volunteers and each, their officers, directors, agents and employees.

Would you like to receive news & updates from SABAH?

Yes, I would like to be added to your mailing list.

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