Paralympic Experience REGISTRATION

The Paralympic Experience will be held  at the Texas Rowing Center, 1541 West Cesar Chavez in Austin, Texas.

Participation is FREE with advanced registration:   The event will be held on May 11..for more information : PARALYMPIC EXPERIENCE 2013

**After completing the form please snail mail the form to:
Diane McDiarmid
Texas Rowing For All
1541 West Cesar Chavez
Austin, Texas

 PARALYMPIC EXPERIENCE

Individual Registration Form

** (One form per participant) **

First Name: _______________________________ Last Name: __________________________________

Age: _________ Date of Birth: ___________________ Gender: ? Female ? Male

Address: _______________________________________________________________

City: ____________________________ State: _________ Zip: __________________

Primary Phone: _________________________________ ? Cell ? Home ? Work

Email Address: ______________________________________________________

Sport involvement: ? Recreational ? Developmental ? Emerging ? Elite/National

Sport preference: _________________________________________________________

Sports Classification (s): ___________________________________________________

Swimming Ability:   ______________________________________________________ (please explain).

Disability (if applicable):

? Amputee

? Blind / Visually Impaired

? Cerebral Palsy

? Spina Bifida

? Spinal Cord Injury

? Traumatic Brain Injury / Stroke

? Other (please specify): __________________________________________________________________

Are you a Veteran or active duty service member? ?   (please circle)        Yes         No

Send to:      Texas Rowing For All    5715 Bexley Ct.  Austin, Texas  78739

Thank you