Hiker Regisration

Hiker First Name *

Last Name *

How did you hear about Luke5Adventures?

Submit as a company

Company Name

Phone 1

Email *

Communication Preference

Data Privacy & Consent

Yes, I would like to receive text messages from Luke5Adventures Flagstaff Chapter.

Date of Birth

Gender

Height

Weight

Address Line 1

Address Line 2

City

State/Province

Zip/Postal Code

Country

Create an account to save your information and access our online portal!

Login Name

Password

Retype Password

What is the hiker's main diagnosis?

Parent(s) or Caregiver(s) Name(s) (if applicable)

Name & Age of anyone else that may join you

How does the hiker communicate? Do they use a communication device?

Does the hiker use a mobility device? If yes, which device?

Describe the hiker's muscle tone, head control, trunk control and balance?

How does the hiker transfer from wheelchair to Rosie?

What are the hiker's likes and interests? Favorite activites?

What are the hiker's dislikes/triggers? If applicable, which calming techniques are preferred?

Does the hiker have history or present levels of physical aggression?

What medical devices (internal/external) that will be present, and may need attention on the hike?

Does the hiker have food or environmental allergies? (poison ivy, bees, etc)

What additional information would you like to share with our LA5 Sherpa Team for the hiker's experience?

Are you involved in a local church?

Yes

No

If so, where do you attend?