NRSE Adaptive Cycling Registration

Rating Abbreviation

First Name

Last Name

Email

What is your branch affiliation?

U.S. Coast Guard

U.S. Navy

Other

None of the above

Status

Active Duty

PDRL

TDRL

I am not sure

Other, please identify in comments box below.

What is your affiliation with Navy Wounded Warrior?

I am currently enrolled.

I was previously enrolled.

I have never been enrolled.

I am unsure of my status.

If you will be accompanied by a non-medical attendant, please include their first and last name.

Emergency Contact First & Last Name

Emergency Contact Phone Number

Special Requests (service animal, dietary needs, sensory concerns, etc.)

Comments

Cycling Experience

Your answers to these questions help us ensure your experience is tailored to meet your specific needs. NOTE: Higher traction tires such as those on a mountain bike will tire you out quicker. For these events, it's recommended to have a bicycle with smoother tires.

Can you ride a bike?

Yes

No

Do you own your own bike?

Yes

Yes, but it has high-traction tires (mountain bike, trail riding, etc.)

No

Is it in good condition and been recently serviced?

Good condition and recently serviced

Good conditioned, but serviced more than a year ago

No

I am unsure