Participant Registration

 

Participant Information

1. First Name RequiredMinimum number of characters not met.Exceeded maximum number of characters.
2. Last Name RequiredMinimum number of characters not met.Exceeded maximum number of characters.
3. Date of Birth Required Ex: 2009-08-16Invalid format Ex: 2009-08-16
4. Address RequiredExceeded maximum number of characters.Minimum number of characters not met.
5. City RequiredExceeded maximum number of characters.Minimum number of characters not met.
6. State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Required
7. Zip RequiredInvalid format.
8. Phone Required Ex: 1234567789Invalid format Ex: 1234567789
9. Email Required Ex: myname@email.comInvalid format Ex: myname@email.com

Emergency Contact

1. Name RequiredExceeded maximum number of characters.Minimum number of characters not met.
2. Relationship Mom Dad Sister (18+) Brother (18+) Spouse Aunt Uncle Grandma Grandpa Other Required
3. Phone Required Ex: 1234567789Invalid format Ex: 1234567789

Do you have a Spinal Cord Injury?

C-1	C-2	C-3	C-4	C-5	C-6	C-7	C-8
T-1	T-2	T-3	T-4	T-5	T-6	T-7	T-8
T-9	T-10	T-11	T-12
L-1	L-2	L-3	L-4	L-5
S-1	S-2	S-3	S-4	S-5
Incomplete	Complete

Are you an Amputee?

1. Double above the knee (AK)
2. Single AK
3. Double below the knee (BK)
4. Single BK
5. Double above the elbow (AE)
6. Single AE
7. Double below the elbow (BE)
8. Single BE

Do you have Cerebral Palsy?

1. Monoplegia
2. Quadriplegia
3. Diplegia
4. Triplegia
5. Hemiplegia

Are you Vision Impaired?

1. Visually Impaired
2. Partial Sight
3. Blind
4. Legally Blind
5. Travel Vision
6. Light Perception
7. Total Blindness

Do you have?

1. Shunt
2. Surgical rods or fusions
3. Seizures
4. Diabetes
5. Insulin dependent
6. Hypertension
7. Heart Disease
8. Lung disease/asthma
9. Heat-related problems
10. Stroke
11. Multiple Sclerosis
12. Brain Injury
13. Neuro Muscular Disease
14. Not Listed

Do you have Allergies?

1. LATEX
2. Peanuts/Tree Nuts
3. Bees/Wasps
4. Plant Allergies

How did you hear about RISE? Internet Search Newspaper/Publication Friend Word of mouth Rehabilitation/Therapy Center Hospital RequiredRequired

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