Mobility-Impaired Participant Application

2012 Ski for Light International Week
February 5 - 12, 2012
The Marriott Hotel & Conference Center - Provo, Utah and
Soldier Hollow Cross-Country Ski Area - Midway, Utah

This application is for prospective participants who are mobility-impaired.

Personal Information

1. Last Name: First Name:
Address:

City: State: Zip:
Country:
Home Phone:
Work Phone:
Cellphone: (if any)
E-mail: (if any)

2. Your name, as you wish it to appear on your event name-tag, if different from above.

3. Job or profession

4. Age Date of birth (mm/dd/yy)

5. Gender:
Select One
Female
Male

6. Height: (feet, inches) Weight, necessary for skier matching: (pounds)

7. Please describe your physical disability:

NOTE: While SFL provides each participant with a personal ski guide for the week, the guide is not expected to assist with daily living skills such as showering or dressing. Participants are expected to either be able to do daily independent living skills or provide an attendant at the participant's expense.

8. In addition to your physical disability, do you have a visual or hearing impairment?
Select One
Yes
No

If Yes, please describe:

9. Do you require, if available, a lift-equipped bus?
Select One
Yes
No

10. If a lift-equipped bus is not available, are you able to transfer independently, or with limited assistance, to a car or mini-van?
Select One
Yes
No

11. Have you previously attended Ski for Light International?
Select One
Yes
No

If yes, number of previous events attended:

If yes, most recent year attended:

12. What is your current level of cross-country skiing ability?
Select One
Beginner
Intermediate
Advanced

13. First-time participants: briefly describe any previous cross-country skiing experience:

14. Are you a medical professional, or certified in First-aid or CPR?
Select One
Yes
No

If Yes, please describe below, including the type and expiration date of your certification:

Rooms, Meals and Other Event Preferences

15. On what day will you arrive at the Provo Marriott?

16. Please indicate below your hotel rooming preference. Prices shown include room and all meals from Sunday evening February 5 through Sunday morning February 12, round-trip transportation between the Salt Lake City (SLC) airport and hotel, transportation to/from the ski area each day, all trail fees, and use of sit-ski and poles for the week.
Select One
Double-occupancy, in an ADA (wheelchair-accessible) hotel room with two double beds or one king bed, $850 per person
Double-occupancy, in a standard hotel room with one king or two double beds, $850 per person
Single-occupancy, if available, in an ADA (wheelchair-accessible) hotel room with one king or two double beds, $1,175
Single-occupancy, in a standard hotel room with one king or two double beds, $1,175

NOTE: Full payment is due from all accepted applicants by December 15, 2011.

17. What is the name of your preferred roommate, if any?


18. There are eight ADA (wheelchair-accessible) rooms in the hotel. Of these, five have a roll-in shower and three have a shower bench. All eight have 36" doorways and low closet bars and bathroom counters. If you have requested an ADA (wheelchair-accessible) room, which type of bathroom do you require?
Select One
Shower bench
Roll-in shower
Not applicable

19. SFL recognizes that some first-time participants will not be able to attend the event without financial aid. Partial stipends are available in such situations, under the following guidelines: the amount awarded will be based on the funds that SFL has available, the applicant's demonstrated financial need, and the applicant's total cost of participating (including travel costs). Assistance is not available to applicants arriving early and/or staying late at the event hotel, or to applicants with a single room. If you would like to be considered for financial assistance, please indicate your total household income and provide a narrative paragraph describing why you need financial assistance.

20. SFL strives to provide a healthy, balanced diet that is high in complex carbohydrates derived from fresh fruits and vegetables, whole grains and dairy products and low in fat. Which of the two available meal options would be your preference?
Select One
Standard - includes red meat, poultry and fish.
Pescatarian - includes eggs, dairy products and fish as well as other sources of protein (legumes and soy) but no red meat or poultry.

NOTE: The standard and pescatarian menu options are the only menu options that will be available during the week. SFL is able to secure affordable meal prices that benefit all participants by limiting the menu options to just these two. Thank you for understanding and cooperating with these choices.

21. Skiing Plans or Goals for the Week:
Select the option that best describes your skiing plans or goals for the week.
Select One
I plan to ski hard over a considerable distance every day to improve my competitive skills.
I plan to ski more recreationally than competitively but to ski a good distance every day.
I plan to ski recreationally but not cover too great a distance every day.
I plan to ski at a more leisurely pace over relatively short distances.
None of the above (please explain below.)

Please provide any additional or clarifying comments on this subject:

Other Information

22. A list of attendees is distributed to participants at each Ski for Light event. Do you wish to include your home telephone number with your name and address on the list? Yes No

23. The Ski for Light Bulletin is a newsletter that informs people in the SFL community about events and activities of interest. It is distributed three times a year in print and e-mail editions. Which of these two versions would you prefer to receive
Select One

e-mail

print

24. First-time participants: how did you learn of SFL International? Please be specific.

Additional information or comments, if any, for Dianne Brunswick, the Application Coordinator:

If you have questions please contact:
Dianne Brunswick
Mobility-Impaired Participant Application Coordinator
4627 W. Kings Avenue
Glendale, AZ 85306
(602) 504-3521 (home)
DMBrunswick@msn.com