Hiker Registration

First Name: Last Name: Birthday(MM/DD/YYYY): / / Gender: Female Male Email: Phone: 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: - Zip Suffix Communication Preference Name of Parent(s) and/or Caregiver(s) (if applicable): Names of family members who may join us (provide age if under 18): Communication Style Please share details regarding Communication Style choice (beyond Verbal): If applicable, please select those that apply: Please share details regarding choices made above: Are there behavioral signs or triggers to be aware of to aid in ensuring the Hiker is comfortable and remains at ease? Any specific calming tools or techniques? Any environmental allergies (e.g., stinging insects, ragweed)? Height Weight Able to stand/bear weight on legs? Ambulatory? If so, what are limitations? If yes, please explain limitations: Will transfer assistance be needed? If so, will a parent or caregiver be present? If yes, will a parent or caregiver be present to aid or direct seating? Please check all that apply related to Rosie (one-wheeled hiking device) chair seating: If any boxes checked above, please provide specific details: Describe sitting balance (e.g., independent, independent with support, requires full support, does not have active trunk control): Describe overall muscle tone (e.g., normal, low tone, high tone, fluctuating tone): Describe head control: Sherpas (volunteers) are available to carry any necessary equipment to support a Hikers’ comfort and safety needs on an adventure (hike). Will any equipment need to be carried? If yes, please describe what needs to be carried: I have read the Luke5Adventures and Luke5Adventures Tucson "Release of Liability" document and agree to the statements mentioned within it. (Please type your name here as your signature of acknowledgement.) I give my consent to be photographed/videotaped and for my image/video recording to be used in print/ format and on social media by L5A and L5A Tucson. I understand that if I want to revoke this permission in the future, I must make this request in writing to the Director of Luke5Adventures and Luke5Adventures Tucson. (Please type your name here as your signature of acknowledgement.) Hiker's Family & Friends (Please let us know information about people and pets that are important to the hiker.) : Hiker’s favorites (e.g., people, places, things, hobbies, foods, movies, TV shows)? Is there any additional information Luke5Adventures Tucson should be aware of that has not already been addressed? How did you hear about Luke5Adventures Tucson?