Pedal-Paddle

To be considered for Pedal~Paddle, please complete the application below:

Paralympic Athlete Camp Application

I am applying for the following camps:

Alpine Ski & Race Camp January 9-13, 2019Nordic Ski & Race Camp February 7-10, 2019Mono Ski Madness March 1-3, 2019Biathlon Camp March 13-17, 2019June Lake Triathlon July 13, 2019Sierra Cycle Challenge July 27-29, 2019Pedal~Paddle August 23-25, 2019Mammoth Gran Fondo September 7, 2019

Athlete Information

First Name

Last Name

Date of Birth

Address Line 1

Address Line 2

City

Country

Please select... United States Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos ( Keeling ) Islands Colombia Comoros Congo Cook Islands Costa Rica Côte d ' Ivoire Croatia ( Hrvatska ) Cuba Cyprus Czech Republic Congo ( DRC ) Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands ( Islas Malvinas ) Faroe Islands Fiji Islands Finland France French Guiana French Polynesia French Southern and Antarctic Lands Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong SAR Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao SAR Macedonia, Former Yugoslav Republic of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Samoa San Marino São Tomé and Prìncipe Saudi Arabia Senegal Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands Spain Sri Lanka St. Helena St. Kitts and Nevis St. Lucia St. Pierre and Miquelon St. Vincent and the Grenadines Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Viet Nam Virgin Islands ( British ) Virgin Islands Wallis and Futuna Yemen Zambia Zimbabwe

Provinces

Please select... Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon

State

Please select... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District 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 Puerto Rico Virgin Island Northern Mariana Islands Guam American Samoa Palau

State/Province

Postal Code

Email

Phone

Gender

Please select... Male Female

Do you have a USSA license?

YesNo

USSA Number

Do you have an IPC license?

YesNo

IPC Number

Emergency Contact

Phone

Do you have an IPC classification?

YesNo

Alpine Skiing Disability Classifications

B1 - totally blind participants with vision up to light perception/hand movementB2 - visual acuity of 2/60 and/or visual field of less than 10 degreesB3 - visual acuity above 2/60 to 6/60 and/or visual field of less than 40 degrees or a low visual acuityLW1 - double above-knee amputees or similarLW2 - significant impairment in one leg, using one skiLW3 - moderate impairment in both legs /CP5, CP6. Ski with two skis and prosthesisLW4 - skiers with below-knee amputation using prosthesis, two skis and polesLW5/7 - skiers with both hands/arms amputated unable to use poles (LW5/7-1, LW5/7-2, LW5/7-3)LW6/8 - skiers with one hand/arm amputated using one pole (LW6/8-1, LW6/8-2)LW9 - skiers wtih disability of one arm and one leg (amputation, CP, Hemiplegia), (LW9/1, LW9/2LW10 - mono skiers (high level of spinal cord injury), (LW10/1, LW10/2LW11 - mono skiers (thoracic spinal cord injury)LW12 - mono skiers (paraplegic or double AK amputees), (LW12/1, LW12/2)

Nordic Skiing Disability Classifications

B1 - totally blind participants with vision up to light perception/hand movementB2 - visual acuity of 2/60 and/or visual field of less than 5 degreesB3 - visual acuity above 2/60 to 6/60 and/or visual field of more than 5 degrees and less than 20 degreesLW2 - impairment in one entire lower limb. Skiing with two skis and two ski poles LW3 - impairment in two lower extremities which includes whole and/or partial limb dysfunction. Skiing with two skis and two ski polesLW4 - impairment in one lower limb below the knee. Skiing with two skis and two ski polesLW5/7 - impairment in both upper limbs withoutthe use of prosthesis. Skiing with two skis and no ski polesLW6 - impairment in one entire upper limb without use of a prosthesis. Skiing with two skis and one ski poleLW8 - impairment in one upper limb below the elbow. Skiing with two skis and one ski polLW9 - combination of impairments in both the upper and lower limbs. Skiing with two skis and either one or two ski polesLW10-12 - disability impairments in the lower limb(s) and the trunk. Skiing sitting. (LW10, LW10.5, LW11, Lw11.5, LW12)

I have already completed the DSES Student Information Form

YesNo

Contact Information