CCSA Student Registration Form

PLEASE NOTE
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Skier Information

First Name Last Name
Primary Phone Secondary Phone
Address City
State Zip
Parent / Guardian Name Email
Height Weight
Shoe Size Shirt Size
Birthdate
Tell us how you learned about CCSA

Emergency Contact Information

Name
Primary Phone Secondary Phone

Program Preferences

Lesson Day/Time (Indicate choice by 1,2,3)

Tuesday 6-8p Wednesday 6-8p Thursday 6-8p
Sunday 1-3 Sunday 2-4 Sunday 3-5
If there is a volunteer instructor with whom you wish to ski, please note name here:
Will you need rental skis? (Please do not check if you will be using a sit ski (mono or bi)

Skier Disability

Other
Please describe disability in detail to assist staff in placement:

Adaptive Discipline:

Is skier currently under doctor's care for any condition, please specify:
Are there any limitations on the skier's activities? Please describe:
Medical Precautions (Please describe):
Seizures:
If yes, is it controlled by medication?
Type:
Last seizure:
Allergies:
Is skier a HEPATITIS B or C carrier?
Does skier have Down'S Syndrome?
If skier has Down's Syndrome, verification of atlantoaxial dislocation is needed. A doctor's signature is required.
Special diet? If so explain:
Does skier need assistance with
  If so, explain
  If so, explain

Does the skier have any particular behaviors that staff should be aware of? If so, please describe.

Sit-Down Skiers

Will rolling sideways onto the shoulders cause pain or injury to the back or shoulders, or cause dizziness?
Can the skier push the wheelchair independently?
Within the past six months, has there been any injury to, or surgery on, the back, spinal cord, or hips?
Does the skier wear a back brace?
If yes, describe brace:
Do you have Harrington Rods?
If so, then please specify the length of time you've had them:

As a student or parent would you be interested in working on a committee.


2018 Rates

Click on the price below to pay via Paypal or by Credit Card
6 Year Old Fee    7+ Year Old Fee
Weekday Series 40    155
Weekday Series with Rentals 90    225
Weekend Series 40    225
Weekend Series with Rentals 90    295
We only ski students six and above. Payment is required prior to the first lesson. You may pay by US Mail, online, or at the first lesson.