Fishing Tournament Registration

CONTACT/BIOGRAPHICAL INFORMATION

Today's Date*

Participant Name*

First Last

Date of Birth*

Age*

Gender*

Participant Address*

Street Address Address Line 2 City State ZIP Code

Primary Phone*

Other Phone

Email Address*

Enter Email Confirm Email

Name of Parent/Guardian (if applicable)

First Last

Relationship to Participant

Parent/Guardian Phone

Name of Emergency Contact*

First Last

Relationship to Participant*

Emergency Contact Phone*

Primary Physician*

Physician Phone*

DISABILITY/MEDICAL INFORMATION

Disability/Diagnosis (please be specific and list all that may affect participation)

If disability was caused by injury/incident please give the date

Allergies (food, medication, other)?*

Yes
No

If yes, please list allergies and known reactions*

Does the Participant have a shunt?*

Yes
No

Any surgeries in the past year?*

Yes
No

Give Date of Surgery*

Give reason for surgery*

Any significant injuries in the past year?*

PLEASE NOTE: The AGRED Foundation requires medical clearance for clients who have had surgery or experienced a significant injury within 12 months of first scheduled participation date.

Yes
No

Give Date of Injury*

Describe Injury*

Is the participant subject to seizures?*

Yes
No

Give Date of Last Seizure*

Describe Seizures*

Currently taking any medications?*

Yes
No

List Medications*

Please list primary reasons for and side effects of medications that may impact participation*

Please describe any other medical concerns that may impact participation

PHYSICAL & SOCIAL INFORMATION

Participant Height*

Participant Weight*

Please describe the participant’s mobility*

Independent
Independent, requires extra time
Needs Assistance

Please describe any devices used to aid mobility (check any/all that apply)*

Braces
Cane
Crutches
Walker
Manual Wheelchair
Power/Electric Wheelchair
Other

You selected "Other" above; please list*

Please describe participant’s ability to transfer (if applicable):*

Independent
Independent, requires extra time
Needs Assistance

Please describe strength and use of upper and lower extremities as it pertains to function, strength, and range of motion*

If the participant has a hearing impairment please describe hearing and any special needs/concerns*

If the participant has a visual impairment please describe vision and any special needs/concerns*

Please describe any pertinent information regarding the participant's means of communication and interactions with others. Please include any stressors, motivators or other information if the participant has a cognitive disability.*

Should you have any questions about your registration, please feel free to contact The AGRED Foundation. We can be reached by phone 318.210.0451; fax 318.222.7222; or email patrick@palube.com

Post Title

Fishing Tournament Registration

2021 Wounded Patriot Fishing Tournament on Lake Erling Registration

CONTACT/BIOGRAPHICAL INFORMATION

DISABILITY/MEDICAL INFORMATION

PHYSICAL & SOCIAL INFORMATION