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First name*

Last name*

Phone number*

Email address*

Address*

Additional information

Date of Birth*

Is your current classification up for review?*

Yes

No

Previous Classification- Track

Previous Classification- Field

Are you currently classified in another sport?*

If you selected "Yes"on the previous question- Are you classified in another sport?- please list all other classifications you currently have

Please indicate the medical diagnosis of your physical impairment*

Condition of Impairment*

Acquired

Congenital

If you listed your physical impairment as "Acquired" please provide the date of onset

Impairment Description- please provide a description of functional impairment/disability* Max. 255 characters

Other disabilities/ impairments- please list any other disabilities and/or impairments you have in addition to your physical impairment Max. 255 characters

How long have you been involved in athletics?*

Please indicate how many training sessions you do per week*

Please attach medical documentation and any additional documents to assist the classification team.*

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Appointment Preference*

Thursday AM

Thursday PM

Friday AM

Friday PM

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Are you attending this event?

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