Join CrossFit Pushin' Weight — Uniquely Abled Fitness

INTAKE QUESTIONNAIRE

CrossFit Pushin’ Weight

We are so grateful you and your athlete are joining our Uniquely Abled Fitness family! Please fill out the following form thoroughly as it will help us serve your athlete best in their fitness journey.

Our mission: Uniquely Abled Fitness exists to enable individuals with intellectual and developmental disabilities to engage in an inclusive fitness program where each athlete can grow physically, emotionally, and socially.

Full Name of Uniquely Abled Participant

First Name

Last Name

Preferred Nickname

Participant Age

Participant Date of Birth

What type of special need does your athlete experience?

(i.e. Down Syndrome, Autism, etc.)

Does your athlete experience any sensory sensitivities?

(Tactile, audible, visual, etc.)

Please list all physical activities your athlete currently participates in.

(School sports, Special Olympics, etc.)

Does your athlete have any physical limitations?

Does your athlete have any medical conditions?

Does your athlete have any allergies?

Please list any additional information about your athlete that our coaches should know:

Name of Parent/Legal Guardian

First Name

Last Name

Please note the listed guardian's relationship to athlete:

Parent/Legal Guardian Phone Number

Please list all desired contact numbers for updates on classes, events, etc.

(###)

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Parent/Legal Guardian Email

Please list the primary email for updates on classes, events, etc.

Please list any individual that has permission to pick up your athlete:

Emergency Contact Name:

First Name

Last Name

Emergency Contact Phone Number:

(###)

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Photo/Video Consent

As the parent/legal guardian of this athlete, I grant Uniquely Abled Fitness my permission to use photographs/videos of my child for any use including, but not limited to: illustration, advertising, marketing, and web content.

I consent

I do not consent

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