2025-2026 Private Ski/Snowboard Lesson Registration

First Name: Last Name: Best Phone Number: Email: Primary Contact Myself Caregiver Parent Primary Contact Phone (if different from above) Primary Contact Email (if different from above) Primary Contact Name (if different from athlete) Emergency Contact Name: Emergency Contact Phone Number: Birth Date: / / Gender: Female Male Non-conforming/Gender variant Prefer not to say Address: Address Line 2 City: State: 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 American Samoa Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico U.S. Minor Outlying Islands Virgin Islands Armed Forces Americas Armed Forces Europe, the Middle East, an Armed Forces Pacific Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Territory Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory Zip Code: - Zip Suffix Start year with ASPNM How did you hear about ASPNM? Type of Disability Description of disability: What functions are affected? What type of skiing/riding do you think you will be doing Stand Up Skiing Stand Up Snowboarding Sit Down Skiing - Bi-Ski Sit Down Skiing - Mono Ski Ski Bike Do not know Do you experience seizures? If yes, date of last seizure Able to follow instructions? Yes No Other Food or medication allergies: Verbal Communication Verbal Non-verbal Other Please describe any hearing/vision impairments. If not applicable, type N/A. Mobility/Assistive Devices: Ability to sense cold in extremities: Height: Weight: Current physical activities: Medications: Do you need to limit activities in any way? Ethnicity Race Military Service Which Military Branch did you serve in (select all the apply) Annual Household Income Less than 30,000 30,000-44,999 45,000-89,999 90,000 or more Prefer not to say Captcha Create a Login Name: Login Password: Retype Password: If you have a coupon, please enter code here (case-sensitive):