Wheelie Club: Summer Camp Registration

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This form is required to participate in the Wheelie Club Summer Camp. By systematically recording participant details, such as demographics, activity preferences, and registration patterns, the facility gains insights that enable program development. Our goal is to provide the highest level of programs possible for the OKC community. Paper copies are available upon request.

Name *

First and Last Name of the person filling out the survey.

Participant's Name *

First and Last Name of the child who will participate in Wheelie Club's Summer Camp.

Emergency Contact *

Name, Phone Number, and Relationship

What is the nature of your child's diagnosis?

(Optional)

Ataxia: Uncoordinated movements caused by damage to the central nervous system

Athetosis: Athletes with Athetosis have continual slow involuntary movements

Hypertonia: Athletes with Hypertonia have an increase in muscle tension and a reduced ability of the muscles to stretch caused by damage to the central nervous system.

Impaired Muscle Power: Health Condition that either reduces or eliminates their ability to voluntarily contract their muscles.

Impaired Passive Range of Movement: Lack of passive movement in one or more joints

Intellectual Impairment: A restriction in intellectual functioning and adaptive behavior in which affects conceptual social and practical adaptive skills required for everyday life.

Leg Length Difference: Difference in the length of their legs as a result of a disturbance of limb growth.

Limb Deficiency: Total or partial absence of bones or joints as a consequence of trauma.

Short Stature: Have reduced length in the bones of the upper limbs, lower limbs and/or trunk

Vision Impairment: Have reduced or no vision caused by damage to the eye structure.

No Diagnosis or Impairment

Other:

Does your child have any food allergies? *

Tree Nuts

Lactose

Other:

Required

Participant's T-Shirt Size *

Youth XS

Youth S

Youth M

Youth L

Youth XL

Youth XXL

Adult XS

Adult S

Adult M

Adult L

Adult XL

Adult 2XL

Adult 3XL

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