Registration: 4 Leaf Clover 10K-Captains

USER INFORMATION
First Name: * 
Last Name: * 
Address: * 
City: * 
State: * 
Zip: * 
Email: * 
Confirm Email: * 
Phone: * 
Birthdate (mm-dd-yyyy): * 
Gender: * 
Shirt size: * 
List the primary diagnoses/injuries that resulted in your disability:: * 
How long have you had your disability::: * 
Describe your level of disability using a wheelchair:: * 
Describe your level of disability using an assistive device:: * 
Describe your level of disability using transfers:: * 
Please list any other pertinent information concerning your disability:: * 
Do you have a history of seizures? (Y/N):: * 
Are you continent? (Y/N):: * 
If yes, please tell us how often, how long they last, when you are about to have them, and if there is anything that can be done to help you through the seizure.: * 
If no, do you require any special accommodation during the race? Please explain.:: * 
Would you require any special feeding during the race? (Y/N):: * 
If yes, please explain.:: * 
How often would you need to drink water and would you need help?:: * 
Are there any other medical or physical issues that we should be aware of? Please explain.:: * 
Height: * 
Weight: * 
Person Completing Registration.: * 
Relationship to Captain: * 
I agree to the terms and conditions: *  
 Read Terms & Conditions