Athlete Name
*
First Name
Last Name
I (athlete) prefer to be called:
Date of Birth
*
MM
DD
YYYY
Athlete Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Athlete Phone
*
(###)
###
####
Athlete Email
Parent/ Substitute Decision Maker Name
*
First Name
Last Name
Parent/ Substitute Decision Maker Address (If different from above)
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Parent/ Substitute Decision Maker Phone (If different from above)
*
(###)
###
####
Parent/ Substitute Decision Maker Email
*
Secondary or Other Parent/ Substitute Decision Maker Name
First Name
Last Name
Secondary or Other Parent/ Substitute Decision Maker Address (If different from above)
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Secondary or Other Parent/ Substitute Decision Maker Phone (If different from above)
(###)
###
####
Secondary or Other Parent/ Substitute Decision Maker Email (If different from above)
Primary Diagnosis
*
Secondary Diagnosis
*
For participants with Down Syndrome, please indicate test results for Atlanto-axial dislocation below:
Please note that you will have to provide proof of test results if requested by the Guelph Giants.
Physically
*
Cognitively
*
Socially
*
List any medical concerns (E.G. Seizures, respiratory, medications, communicable diseases, etc.)
*
List any allergies (E.g. Medication related, insects, food, environmental, etc.)
*
List any significant health events that could affect participation (E.g. Surgeries, procedures, or injuries)
*
What equipment does the athlete utilize to perform activities of daily living? (E.g. Wheelchairs, braces, etc.)
*
Describe the athlete's behaviour in terms of activity level, attention span, and impulsiveness
*
Please identify any known triggers that may initiate negative behaviour
*
Please indicate any strategies/ techniques that you find useful in managing the athlete's behaviour
*
Has the athlete ever skated or been involved in hockey before?
*
If Yes, did you consider the experience successful?
*
Why or why not?
Do you have any concerns with the athlete being involved with the Guelph Giants hockey program?
*
What are the goals and expectations of the program for the athlete?
*
As a volunteer organization, we rely on you to do what we do. Would you be interested in volunteering to be a part of the Guelph Giants? Please identify the capacity within the team(s) you feel you would contribute most. We require people to help with fundraising and social events, for instance.
Mobility
*
Transfer (E.g. Floor to chair, etc.)
*
In General
*
To get attention of others/ ask for help
*
To communicate basic needs (E.g. Personal Care)
*
A new recreational activity
*
*
