0924c General Ski Information, National Disabled Veterans Wint

Form Approved: OMB No. 2900-0759
Expiration Date: Xxx, 20XX
Respondent Burden: 15 minutes

GENERAL SKI INFORMATION
NATIONAL DISABLED VETERANS WINTER SPORTS CLINIC
PRIVACY ACT: VA is asking you to provide the information on this form under USC, Chapter 5, Section 521 and Chapter 17, Section 1710. VA may
disclose the information that you put on this form as permitted by law. VA may make a "routine use" disclosure of the information as outlined in the
Privacy Act systems of records notices identified as 121VA19 “National Patient Databases - VA”. Providing the requested information is voluntary.
However, you will not be able to participate in the event without furnishing this information.
RESPONDENT BURDEN: The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the
clearance requirements of Section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not required to respond to,
a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who must complete this
application will average 15 minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the forms.
Every participant accepted to this event must participate in their scheduled lesson even if you can
independently ski. Failure to do so will eliminate you from future clinics.
HAVE YOU SKIED SINCE
YOUR INJURY?

YOU WILL BE ASSIGNED TWO SCHEDULED SKI DAYS
PLUS RACE DAY, WHAT DO YOU PLAN TO DO ON YOUR
ASSIGNED DAYS?

WHAT TYPE OF SKIING WILL YOU DO?
(Check all that apply, please be accurate)

YES

ALPINE (Downhill) ONLY

ALPINE & NORDIC

ALPINE ONLY

ALPINE & NORDIC

NO

NORDIC (Cross Country) ONLY

SNOWBOARD

NORDIC ONLY

SNOWBOARD

Please be accurate with what type of skiing you plan to do, you will be assigned prior to arriving and no changes will be permitted.
WILL YOU SKI? (If you are over 220 pounds, you must ski standing up.) WHAT TYPE OF EQUIPMENT WILL YOU USE?
STANDING UP

SITTING DOWN

MONO SKI

THE VISUALLY IMPAIRED MUST CHECK ONE OF THE
ADDITIONAL BOXES
STANDING VISUALLY
IMPAIRED

SITTING VISUALLY
IMPAIRED

BI-SKI

SIGHTED GUIDE

SNOWBOARD

2-TRACK STAND-UP
(Two regular skis and poles)

3-TRACK STAND-UP (One
regular ski and two outriggers)

4-TRACK STAND-UP (Two
regular skis and two outriggers)

FIRST TIME PARTICIPANT,
UNSURE OF WHAT I WILL NEED

WHAT LEVEL OF SKIER ARE YOU? (Only check those that you plan to do at the
clinic)
ALPINE (Downhill)

BEGINNER

INTERMEDIATE

ADVANCED

NORDIC (CrossCountry)

BEGINNER

INTERMEDIATE

ADVANCED

SNOWBOARD

BEGINNER

INTERMEDIATE

ADVANCED

IF YOU SKI STANDING, IF YOU SKI STANDING, AND ARE YOU
DO YOU WEAR LEG
PLANNING TO CROSS-COUNTRY SKI,
BRACES?
WHAT IS YOUR SHOE SIZE?
YES

MENS

NO

WOMENS

CAN YOU SKI COMPLETELY IF YOU HAVE ATTENDED IN THE PAST AND WOULD LIKE TO REQUEST A SKI INSTRUCTOR, PLEASE
LIST THE NAME
INDEPENDENTLY?
YES
NO
ARE YOU PLANNING ON BRINGING YOUR OWN SKI
EQUIPMENT? (If yes, what type of ski equipment will you bring?)
YES
NO

ALL VISUALLY IMPAIRED SKIERS WHO CAN WALK WILL BE REQUIRED TO SKI STANDING UP. HOWEVER, IF
YOU ARE VISUALLY IMPAIRED AND MUST SKI SITTING DOWN DUE TO A MEDICAL CONDITION, YOU MUST BE
22O POUNDS OR LESS. ONLY THOSE INDIVIDUALS WHO ARE 220 POUNDS OR LESS WILL BE ALLOWED TO SKI
SITTING DOWN.
VA FORM
FEB 2014

0924c