NRSE Wheelchair Basketball

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 attend

Emergency Contact First & Last Name

Emergency Contact Phone Number

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

Comments

Wheelchair Rugby Experience

Have you tried wheelchair basketball before?

Yes

No

Do you have back injuries that will prevent you from playing this sport?

Yes

No

I am not sure

Do you have injuries or issues related to your condition or diagnosis that need to be shared with the instructor in advance? If yes, please describe here.

Can you provide medical clearance to play this sport?

Yes

No

I am not sure

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