Participant Application
This form is to apply for Golden Roller Skates programs, it is not a guarantee of acceptance.
The following information will not be shared with the public but will be shared with the Board Members and relevant parties involved within each individual program you will be participating in. 
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Email *
Applicants's Name *
Applicant's Date of Birth *
MM
/
DD
/
YYYY
Applicant Phone Number *
Applicant's Address *
Does the applicant have an active Power of Attorney? If so, Please list their name and number here.
Does the applicant have any medical conditions or implanted devices we should be aware of? *
Does the applicant utilize any adaptive equipment? *
Such as a walker, wheelchair, oxygen, etc.
Does the applicant have any allergies? *
Is the applicant on hospice or palliative care? If so, please describe. *
Which program(s) are you applying for? *
Required
If you are applying for Discover & Thrive, please continue to answer the questions below.
Do you have limitations in regards to walking? If so, please describe below.
Do you have any of the following:
This does not eliminate you from participation, but helps us be prepared to accommodate your needs.
Are there any other medical, mental, or physical concerns we should be aware of?
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