Elephant Butte Athlete Registration

First Name: Last Name: 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 Province (Foreign) Zip Code: - Zip Suffix Email: Day Phone: Gender: Female Male Non-conforming/Gender variant Prefer not to say Birth Date: / / Height Weight Ethnicity Race Are you considered a Wounded Warrior? Military Service Which Military Branch did you serve in (select all the apply) DD 214 # Date of Injury Athlete contact person, IE Parents, Guardians, Yourself Emergency Contact Name Emergency Contact Phone Number Parent/Guardian Name(s) (If under 18) Start year with ASPNM Type of Disability Description of disability What functions are affected? Current activities Seizures If yes, date of last seizure Medications Ability to sense cold Hearing/Vision Comprehension Verbal communication Mobility/Assistive Devices Food or medication allergies Need to limit activities? Primary Care Physician name Primary Care Physician phone Captcha Create a Login Name: Login Password: Retype Password: If you have a coupon, please enter code here (case-sensitive):