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Two Top Mountain Adaptive
Sports Foundation

Providing year round education and recreational activities that provide healthy experiences for disabled athletes.

Stacey Schmader, Executive Director

Bill Dietrich, Associate Director

E-mail: stacey@twotopadaptive.org

(717) 331-6895

Home
About
Volunteer
- Volunteer Form
Our Programs
Events
Lesson Inquiry Form
Contact

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Home
About
Volunteer
- Volunteer Form
Our Programs
Events
Lesson Inquiry Form
Contact

Winter Camp Registration

January 26 – January 28 | January 30 – February 1

Choose a date(s): You may choose one or both camps *

January 26-28
January 30-February 1

Participant Info

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Participant Details

Height *

Weight *

Shoe Size *

Branch *

Rank *

Are you active duty? *

Yes
No

Have you skied/snowboarded before? *

Yes
No

I want to: *

Ski
Snowboard
Mono/Bi Ski

Do you need equipment? *

Yes
No

you List a

Do you have any allergies? *

Yes
No

List allergies if any

Do you have any dietary restrictions? *

Yes
No

List Dietary Restrictions

Are you a registered patient at a hospital? *

Yes
No

List Hospital if applicable

Do you have medical clearance to participate in sports? *

Yes
No

Are you eligible to receive VA services and not barred? *

Yes
No

Disability Information

At least one choice is required.

Disability *

Amputee - Above the knee
Amputee - Below the knee
Amputee - arm
Amputee - bi-lateral
Cognitive (physical is primary)
Diabetes
Hearing Impairment - Partial
Hearing Impairment - Total
Multiple Sclerosis
Post Traumatic Stress Disorder (PTSD)
Seizure Disorder
Spinal Cord Injury
Stroke
Traumatic Brain Injury
Visual Impairment - Partial
Visual Impairment - Total
Other

Other disability details if not listed above

Spinal Cord Injury Level, ex L5

Mobility - at least one choice is required *

AFO/Leg Braces
Crutches/Walker/Cane
Manual Wheelchair - full time
Manual Wheelchair - part time
Power Wheelchair - full time
Power Wheelchair - part time
Scooter
None/Ambulatory
Other mobility

Other mobility details

Accompanying Person if applicable

We allow one family member (caregiver) to attend with you. If someone will accompany you, please fill out the information below. Accompanying person must be 18 or older. (Only one room will be provided. If an extra is needed for your caregiver, it will be at your expense)

Name of Accompanying Person

They plan to:

Ski
Snowboard
Mono/Bi-ski
None

Is equipment needed?

Yes
No

Height (required if equipment needed)

Weight (required if equipment needed)

Shoe size (required if equipment needed)

Emergency Contact

Name *

Phone *

Additional Information

Question/Comment

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