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APPLICATION FORM
2025 Winter XMOGames
February 23 - March 2, 2025
Winter Park, Colorado
Application Deadline December 15, 2024
PERSONAL INFORMATION
First Name
Middle Initial
Last Name
Nickname
Mailing Address
City
State
Zip Code
Phone
Cell Phone
Email
Gender
Age
Birthdate
T-Shirt Size (men’s sizes)
EMERGENCY CONTACT INFORMATION
First Name
Last Name
Relationship
Home Phone
Cell Phone
Work Phone
PERSONAL INFORMATION
Please Check All That Apply
HISTORY
Allergies
Asthma
Mild
Severe
Bleeding Disorders
Brain Injury
Cardiac Limitations
Cerebral Palsy
Diabetes
Epilepsy
Hearing Impaired
Neurological
Concussion
Head Trauma
Seizures
Shunt
OTHER
MOBILITY
Independent
Cane
Guide Dog
DEVELOPMENTAL
Mild
Moderate
Severe/Profound
Autism
Down Syndrome
BEHAVIOR DISORDER
Acting Out
Aggressive
Self-Abusive
Other (Explain)
EMOTIONAL
Anti-Social
Depression
Eating Disorder
Substance Abuse
Suicidal
INSURANCE
Insurance Company Name
Insurance Company Telephone
Insurance ID#
Name of Insured
Relationship To Participant
Allergies
(list all foods/medications/etc.)
Type of Allergic Reaction
(anaphylaxis?)
Bleeding Disorders
(please list anticoagulant medications or blood thinners)
Diabetes
(insulin dependent?)
Seizures
When
Type
Visual Diagnosis/Etiology
(Cause Of Visual Impairment)
Visual Acuity
O.D. (right eye)
O.S. (left eye)
O.U. (left eye)
Visual Aides
(contacts, glasses, magnifiers, sunglasses or sunshields)
Eye Medications
Visual Field Loss
(explain in what eye and where)
Is Participant Able To Sleep On Top Bunk?
Does Participant Wet The Bed?