2019 Annual Information Form
This Annual Information Form (AIF) must be completed and filed with the NSSRA office, prior to registration for 2019
programs, in order for a participant to join any NSSRA program or event. The AIF contains extremely important information
which is necessary for NSSRA staff to plan and execute safe and enjoyable programs. Please complete all information.
PARTICIPANT INFORMATION
Date Completed: _____________ Are you new to NSSRA?
Yes
No Participant is own guardian:
Yes
No
Participant Name: First: _________________________ Middle: _________________________ Last: _________________________
Address: _____________________________________________ City:________________________________ Zip: _______________
Home Phone: _____________________ Cell Phone _____________________ Email: _______________________________________
Sex:
M
F
Date of Birth: _____________________ Height: _____________________ Weight: ___________
Primary Diagnosis: ______________________________________ Secondary Diagnosis: __________________________________
*If Down Syndrome, result of the Atlanto-Axial Instability test:
Positive
Negative
Does participant have a seizure disorder?
Yes*
No Date of last seizure: ____________________________________
*If yes, please complete Seizure Information Form
T-Shirt Size: Adult:
S
M
L
XL
XXL
XXXL
Child:
S
M
L
XL
Accommodations needed for Inclusion:
Group Home Participants Only:
Case Manager: ______________________________ Email: _____________________________ Cell: _________________________
CONTACT INFORMATION
Parent/Guardian Name: _______________________________________ Relationship to Participant: ________________________
Address: ______________________________________________ City:________________________________ Zip: ______________
Home Phone: _________________________ Work Phone: _________________________ Cell Phone: _______________________
Email: ______________________________________________________________________
Parent/Guardian Name: _______________________________________ Relationship to Participant: ________________________
Address: ______________________________________________ City:________________________________ Zip: ______________
Home Phone: _________________________ Work Phone: _________________________ Cell Phone: _______________________
Email: ______________________________________________________________________
Opt In to Receive Text Alerts from NSSRA
Sign up to receive time-sensitive program updates via text. Free to join, regular texting rates apply based
upon your carrier plan. You may unsubscribe at any time.
Yes, sign me up! Phone Number(s): ___________________________________________________________________
EMERGENCY CONTACT INFORMATION
Please list emergency contacts, including yourself if applicable, in order of contact preference.
#1: ____________________________________________________________________________________________________________
First and Last Name
(Primary Contact)
Phone Number (
Home
Work
Cell, please select for # listed)
____________________________________________________________________________________________________________
City
Relationship to Participant
#2: ____________________________________________________________________________________________________________
First and Last Name
Phone Number (
Home
Work
Cell, please select for # listed)
____________________________________________________________________________________________________________
City
Relationship to Participant
Please continue on next two pages.
www.nssra.org
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