Flutie Foundation Water Sports Program with AccesSportAmerica

We look forward to having you join us this summer for the Flutie Water Sports Progam with AccesSportAmerica! We are pleased to provide programming through some amazing organizations serving people of all abilities.

To help prepare for your session(s) each participant or their parent/guardian/caregiver must complete this application prior to starting the program.

Email address will be used for program correspondence and scheduling. Please enter parent/guardian email address where email is a required field.

Participant/Athlete Information (person attending program)

First Name *

Last Name *

Email *

Nickname (if any) The maximum length for the field Nickname (if any) is 500 characters.

Athlete/Participant email (age 13+) The field Athlete/Participant email (age 13+) must be an email.

Address * The field Address is required.

City/Town * The field City/Town is required.

State * The field State is required.

Zip Code * The field Zip Code is required.

Preferred Phone * The phone field Preferred Phone is required.

Phone Type? * The field Phone Type? is required.

Phone 2 The field Phone 2 must be a phone number.

How heard/referred by

Are you active in other AccesSport Programs? * The field Are you active in other AccesSport Programs? is required.

If yes, please tell us which one(s)

This section to be completed by parent or guardian.

I am filling this form out for: * The field I am filling this form out for: is required.

First Name i(if not applying for yourself) The maximum length for the field First Name i(if not applying for yourself) is 500 characters.

Last Name (if not applying for yourself) The maximum length for the field Last Name (if not applying for yourself) is 500 characters.

Address The maximum length for the field Address is 500 characters.

City/Town The maximum length for the field City/Town is 500 characters.

State The maximum length for the field State is 500 characters.

Zip Code The maximum length for the field Zip Code is 500 characters.

Preferred Phone The maximum length for the field Preferred Phone is 500 characters.

Phone Type?

Email The field Email must be an email.

Additional Participant/Athlete Information

This information will help us to provide the best experience for participating athletes as we adapt the program or sport. Please list all on-going medical issues, allergies, behavior issues, medications you are taking, and list any additional information that our staff should be aware of. Note there is a 5000 character limit to each question.

Athlete Date of Birth * The date field Athlete Date of Birth is required.

Athlete's primary diagnosis * The field Athlete's primary diagnosis is required.

On-going medical issues? * The field On-going medical issues? is required.

Allergies? * The field Allergies? is required.

Please list any allergies * The field Please list any allergies is required.

Behavioral Issues * The field Behavioral Issues is required.

Medication * The field Medication is required.

Anything else? The maximum length for the field Anything else? is 5000 characters.

Emergency Contacts

In the event of an emergency, these emergency contacts will be called in the order in which they appear.

Emergency Contact 1 * The field Emergency Contact 1 is required.

Preferred Phone * The field Preferred Phone is required.

Phone Type? * The field Phone Type? is required.

Can receive texts? * The field Can receive texts? is required.

Email * The email field Email is required.

Relationship to Athlete * The field Relationship to Athlete is required.

Emergency Contact 2 The maximum length for the field Emergency Contact 2 is 500 characters.

Preferred Phone The field Preferred Phone must be a phone number.

Phone Type?

Can receive texts?

Relationship to Athlete

Emergency Contact 3 The maximum length for the field Emergency Contact 3 is 500 characters.

Preferred Phone The field Preferred Phone must be a phone number.

Phone Type?

Can receive texts?

Relationship to Athlete