My Name: _________________________________________________________ 

My contact information:

            Daytime phone number: ______________________________________ 

            Email address: ______________________________________________ 

My relationship to the named athlete: __________________________________ 

Name of referred athlete: ____________________________________________

                        ___  Youth                     ___ Adult           

            His /Hers Physical Disability

            ___      Vision Impairment or blindness

            ___       Hearing Impairment or deafness

            ___       Dwarf or short stature

            ___       Cerebral Palsy

            ___       Paralysis or amputee 

Athlete’s Contact information:

Address: ____________________________________________________

City: _______________________ State: ___________ Zip: __________

His/Hers Favorite sports:

1.      _______________________

2.      _______________________

3.      _______________________

4.      _______________________