Maui Partner Program Participants

We look forward to having you join us through our organization/program partner program! We are pleased to provide programming through some amazing organizations serving people of all abilities.

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

Participant/Athlete Information

First Name *

Last Name *

Email *

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

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.

Email * The email field Email 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

I am participating as part of: * The field I am participating as part of: is required.

Person completing this application

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.

Preferred pronouns * The field Preferred pronouns is required.

Are you a veteran? * The field Are you a veteran? is required.

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