Transcription of Warriors Hockey Application Form - SportsEngine
1 PERSONAL INFORMATION*Full Name (First, , Last): *Email Address(es): *Address: Cit y ST ZIP *Hometown () *Hm Phone ( ) Wk Phone ( ) Cell Phone ( )
2 Single Engaged Mar ried Spouse Name Occupation/Employer *What High School Did You Att end? Grad Year Any Post HS Education? Tech/Trade School C ollege P ost Grad Other MILITARY INFORMATION*Branch Served (Check all that apply) A rmy (Active Duty, Reserve, National Guard) Navy (Active Duty, Reserve) A ir Force (Active Duty, Reserve, National Guard) Mar ine Corps (Active Duty, Reserve) C oast Guard (Active Duty, Reserve) Other (Please Specify) *(Please Check All That Apply) I honorably served in a combat zone (Please specify where)
3 _ _____ I honorably served during peacetime I am currently serving my countr y honorably WARRIORSWARRIORSWARRIORSWARRIORSWar riors HockeyApplication For m*Age *Birthdate *Height *Weight *Unit(s) Served With: *Number of Years Served *What year(s)?
4 Rank (optional) DISABILITY INFORMATION*(Please check all that apply) I have a physical disability as a result of serving on active duty in any capacity I have a mental disability as a result of serving on active duty in any capacity*Are you missing any limbs? (Circle one) Y N (If no, skip this section)If yes, please give a description of your amputations
5 *Do you have transportation to and from Warriors practices and games? Y N*Do you require special assistance to get dressed and undressed for Warriors practices and games? (Circle one) Y N Not sure*Please give a brief description of your disability(ies) (be sure to include how you were injured/disabled)
6 *Are you currently receiving care for any of
7 The described conditions? If you answered yes to the above question, do you have now, or are you able to obtain, medical clearance from your care provider to participate in Hockey ? Y N Not sure*Have you ever had, or do you have now, any injury or condition that you feel may prevent you from participating in Hockey ? Y N Not sure*Have you ever had, or do you have now, any injury or condition that you feel may be aggravated by participating in Hockey ? Y N Not sureIf you answered yes or not sure to either of the previous two questions.
8 Please provide a brief explanation
9 *Today, do you feel that you are in good health?
10 Y N *Today
