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ACCESS Fit Stroke Warriors 2024 Registration

Please complete all of the following questions below ...

PARTICIPANT INFORMATION

Participant First Name *

Participant Last Name *

I am my own guardian *

Yes
No

Guardian First & Last Name

Guardian Primary Phone

Guardian Primary Email

Address 1 *

Address 2

City *

State/Province *

Zip *

Gender *

Participant Birthday

// (mm/dd/yyyy)

Participant Age *

Have your ever experienced any of the following medical conditions? *

High Blood Pressure
Stroke
Seizure
Heart Murmur
Heart Attack
Severe Allergies
Arthritis
Asthma
Diabetes
Other, Please List:

Other (Medical Condition)

What type of assistive device do you utilize? *

Manual Wheelchair
Power Wheelchair
Walker
Crutches
Hearing Aids
Visual Mobility Cane
Prosthetic Device
None
Other, Please List:

Other (Assistive Device)

What can the ACCESS Fit Staff and Volunteers do to make you most successful at ACCESS Fit? Please select all that apply. *

Low Music Volume
Verbal Cues
Physical Assistance
Adapted equipment for grip
Visual Schedule/Board
Minimize Distractions
None
Other; Please Enter Below

Other

What Fitness Activities, Sports, and/or Games do you enjoy? Please list all interests below. *

Do you receive the monthly ACCESS of Wilmington newsletter? *

Would you like to receive the monthly ACCESS of Wilmington newsletter? *

Is there anyone else you would like us to add to the monthly ACCESS of Wilmington newsletter list so they can receive updates? If so, please provide their First and Last Name and Email below.

First and Last Name

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ACCESS Fit Stroke Warriors 2024 Registration

PARTICIPANT INFORMATION