Participant Application

ALL applications are subject to final approval by BOEC Program Staff. Completing this application DOES NOT guarantee you a spot in a program. Please read our enrollment guidelines for winter or summer before applying to ensure participation is right for you. If you have further questions regarding eligibility, please call our office (970)-453-6422.

courseId

Affiliation

Long Application?

Course Name

General Interest

Yes

Program Interest

Is the applicant a returning participant to BOEC?

YesNo

To the best of your recollection what was the date of the last event the applicant attended?

What types of programs is this applicant interested in?

Winter-based programs (adaptive ski & snowboard lessons)Summer-based programsBoth summer and winter-based programs

Camp Preferences

Camps:

Frozen Assets Adaptive Ski Program: January 22-26, $1,940

Challenge by Choice #1: June 16-21, $2,390

Challenge by Choice #2: July 28- August 2, $2,390

Challenge by Choice #3: August 11 – August 16, $2,390

Ruby Horse Thief Canyon Canoe Excursion August 26-30 $1450

Creative Minds: September 13-16, $1290

*If scholarship assistance is needed for any of the BIAC opportunities listed below please contact Michael at michael@biacolorado.org. Please note, this application does not guarantee you a spot in your preferred camp. Please check with Michael to see about availability.

Please check which camps the applicant wishes to participate in

Frozen Assets Ski RetreatChallenge By Choice #1Challenge By Choice #2 (Full! Waitlist Only) Challenge By Choice #3 (Full Waitlist Only) Ruby Horse Thief Canyon Canoe ExcursionCreative Minds

First Preference

Second Preference

Third Preference

Please briefly describe the program the applicant wishes to attend

Applicant Information

First Name

Middle Name

Last Name

Birthdate

Phone

(Primary contact for all BOEC programming)

Height (ft.)

(in.)

Weight (lbs)

Gender

Prefer to self-identify

Ethnicity

Please self-identify here

Primary Address

City

State/Province

Zip/Postal Code

Please add Primary Emergency Contact Information (Parent, Guardian, Caregiver, etc...)

First Name

Last Name

Phone

Relationship

Please add the contact information for any additional contacts for this applicant. (Please, add all that apply)

First Name

Last Name

Phone

Relationship

Medical Insurance

Please note: We recommend that all BOEC students be covered by personal health insurance. If medical care for injury, pre-existing condition or any other reason is required during a BOEC course, the student’s personal health insurance will be primary.

Is applicant covered by Medical Care Policy?

YesNo

Medical Insurance Policy (carrier and type)

Policy Number:

Armed Forces

Is the applicant Active Duty Military or a veteran of the US Armed Forces?

YesNo

Is the applicant related to a member of the armed forces who will also be participating?

YesNo

Status

Branch

Rank

Years of Active Duty

Separation Date

Does the applicant have combat related injuries?

YesNo

Date of Onset

Disability/Medical Information

Disability (check all that apply)

None	ADD/ADHD	ALS	Autism Spectrum Disorder
Bereaved	Bipolar Disorder	Cancer	Cerebral Palsy
Cleft Lip/Palate	Cognitive Impairment	Conduct Disorder	Down Syndrome
General Anxiety Disorder	Hearing Impairment	Hemophilia	Learning Disability
Major Depressive Disorder	Multiple Sclerosis	Muscular Dystrophy	Neurocognitive Disorder (Dementia)
Panic Disorder	Parkinson's Disease	Personality Disorder	Physical Injury (amputation)
Prader-Willi Syndrome	PTSD	Schizophrenia	Speech Impairment
Spina Bifida	Spinal Cord Injury	Stroke	Substance Abuse
Brain Injury/Traumatic Brain Injury	Visual Impairment	Other (write in)

Other

In the space provided please include any other pertinent information on disability or diagnosis.

If disability was caused by injury, incident, or accident please give the date.

Allergies/Dietary Restrictions

Does the applicant have any known allergies (please include food, medication, insects, environmental)?

YesNo

If yes, please list all known allergies as well as known reactions.

Does the applicant require Epi?

YesNo

Will the applicant carry their own personal Epi Pen with them?

YesNo

Please check any dietary restrictions or strong preferences the applicant may have (Please list any food-related allergies in the Allergies section above).

None	Vegetarian
Vegan	Gluten-free
Kosher	Halal
Lactose-intolerant	Sugar-free
Thick-it	Portion-control
Other

Please describe any dietary restrictions the applicant may have.

Medical History

Has the applicant received the COVID-19 Vaccine?

YesNo

Within the last year has the applicant had any any operations, hospitalizations or serious injuries?

YesNo

If yes, please list and explain.

Seizures

Is the applicant subject to seizures?

YesNo

Pease list any type of seizures the applicant experiences and the frequency.

Date of last seizure?

Are seizures controlled by medication?

YesNo

Please describe what we may expect of a typical seizure? You may include warning signs, duration, any specific care required, and recovery time.

Medications

Does the applicant take any medications including any prescription or over-the-counter medications?

YesNo

Please list any medications and what they are for.

Medical Conditions

Does the applicant have any of the following conditions? (check all that apply).

None	Visual Impairment
Hearing Impairment	Asthma or any other respiratory conditions
Altitude sickness	High blood pressure
Heart conditions including (heart disease, irregular heartbeat, other)?	Diabetes, Thyroid, or other Endocrine Conditions?
Chronic skin problems including rash, infection or poor circulation?	Reaction to extreme temperatures including frostbite, sunburn or heatstroke?
Bone or joint issues including broken bones, arthritis, joint dislocations, serious sprains	Other

Please describe the above conditions that may affect the applicant's participation.

Mobility Information

Does the applicant ever need assistance with mobility, such as requiring extra time, using wheelchairs or assistive devices, etc...?

YesNo

Please describe participants mobility.

Does the applicant use any of the following devices to aid in mobility?

Crutches	Cane/Walker
Prosthetic	Power Chair
Manual Chair	Other

How often does the applicant use a wheelchair?

Does the applicant use the wheelchair independently?

YesNo

What is the width of the wheelchair seat (inches)?

Typical Transfer

Is the applicant able to walk?

YesNo

How far can the applicant walk before resting?

Does the applicant require assistance on uneven or rough terrain?

YesNo

Can the applicant navigate stairs independently?

YesNo

Strength

Does the applicant have any functional limitations in your upper body, hands or feet (This may include, poor muscle tone, limited range of motion, rigidity, spasticity, tremors, etc...)?

YesNo

Please describe.

Does the applicant have a dominant side?

Upper Body Strength

012345

Lower Body Strength

012345

Balance

012345

Communication/Behavior

How does the applicant communicate best?

Verbally	Non Verbally
Yes/No Questions	Sign Language
Devices	Gestures/Body Language
Other

Has the applicant been diagnosed with PTSD?

YesNo

Date of onset

Please select all that apply.

None	Get angry easily	Panic attacks
Get anxious easily	Self isolate	Flashbacks
Hyper-vigilant	Other	Crowd anxiety
Sensitive to loud noises

Please list any triggers.

How should we support the applicant should they become anxious, stressed, fearful, etc...?

Do any of the following conditions apply to the applicant?

None	Short-term memory loss
Problem-solving difficulties	Decreased attention span
Inability to concentrate	Impulsive/decreased ability to filter speech/actions
Other

Please describe

Activities of Daily Living

Due to the adventure focus of BOEC programs, daily living tasks can be challenging for our students. Do you require assistance with any general hygiene (Including bathing, dressing, daily grooming, toileting)?

YesNo

Please select any hygiene related tasks the applicant may need help with.

DressingToiletingBathingDaily GroomingEating/Drinking

Please specify how much assistance the applicant may need with selected tasks.

Toileting Aids

Urinal	Catheter
Toilet Chair	Diapers
Ostomy Bag	Other

Please explain how we can assist the applicant in their daily toileting needs including your bowel & bladder routine, etc....

Experience/Goals

What does the applicant like to do for fun?

Please list any goals or opportunities you would like to work towards? (These can include social, physical, or recreational goals)

Please describe any outdoor recreational experiences the applicant may have (camping, hiking, water sports, rock climbing, etc...)

Winter

Interested in a lesson at:

Breckenridge Ski Resort	Keystone Ski Resort
Copper Ski Resort	Arapahoe Basin Ski Resort
Unsure	Multiple lessons at multiple locations
Breckenridge Nordic Center	N/A

Ski Method

Skiing Ability

Snowboarding Ability

Does the applicant have previous ski or snowboarding experience before the onset of their disability?

YesNo

Does the applicant have previous ski or snowboarding experience after the onset of their disability?

YesNo

Please comment on previous ski experience. Include any known details such as ski type, terrain skied, etc...

Will the applicant bring their own ski or snowboard equipment?

YesNo

Files and Attachments

Please upload any documents such as medication records, vaccine cards, etc...

Newsletter

Check to stay up to date on BOEC via the Monthly Inspirations E-Newsletter.

Comments, Questions, or Concerns

Additional comments, questions, or concerns

Application Acknowledgement

The Breckenridge Outdoor Education Center is committed to offering quality outdoor education to people of all abilities. All prospective students are required to fill out this student application. The above information assists the BOEC in maintaining a risk managed environment. Not completing this form as accurately and truthfully as possible, providing misinformation, or leaving out certain information could result in an injury or may compound the severity of an injury. This information will be kept confidential. We reserve the right to screen all students and may request that you provide a personal caregiver to join the program.

I have read the above application acknowledgement and agree to its conditions.

I understand that the winter application process must still be completed by calling the BOEC ski program office at (970)453-5633 to confirm my application was received

I understand

BIAC Application Fees

Note: All participants must include a $100 registration fee with the application, which is non-refundable. Upon

acceptance of the participant’s application, ½ of the participant fees are due. The remainder is due 30 days

prior to the program’s start date.

The $100 deposit can either be paid

1. by check and sent to:

Brain Injury Alliance of Colorado

1490 Trenton St.

Denver, CO 80220

OR 2. online by credit/debit card.

To pay with card please contact at michael@biacolorado.org or 720-907-1455.

Please note that the applicant is not enrolled until the online application, online waiver, doctors form and $100 deposit have been received.

Upon submission, you will be redirected to complete our Release of Liability and Statement of Informed Consent documents. These must be signed on the applicant's behalf in order to participate in a BOEC program.