First Name: Last Name: Birth Date(MM/DD/YYYY): / / Gender: Female Male Email: Phone: Address: 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(s) of Parent(s) or Care Giver(s) (if applicable): Names and Ages of Siblings (if hiking with us): Height Weight How does the hiker communicate? (verbal, nonverbal, sign language) What are the hiker's likes, dislikes, favorite activities? What are the hiker's behavioral signs/triggers? What calms him/her? What are the hiker's main diagnoses? Check if Applicable other Environmental allergies? (poison ivy, stinging insects, etc) Is the hiker able to stand/bear weight on their legs? How do they transfer? Is assistance needed? Will a parent or caregiver be present to assist with transfers? Is the hiker ambulatory? If so, what are his/her limitations? Describe overall muscle tone: (e.g., normal, low tone, high tone, fluctuating tone, etc.) Head Control? What is the hiker’s sitting balance: independent, independent with support, requires full support, does not have active trunk control, etc.? Medical considerations pertinent to safety and harnessing If you checked any boxes above, please elaborate: Does the hiker have contractures or other medical conditions that affect their sitting posture? Please describe (e.g., hip dysplasia, scoliosis, etc.). Does the hiker use positioning aides? Please describe. We supply sherpas to carry necessary equipment on hikes. Will you need any equipment carried? Is there any additional information which you think might be helpful to our L5A team for this experience for you/your hiker? Are you involved in a local church? If so, where?