Adaptive Skiing Breckenridge Outdoor Education Center (BOEC)

Join The Brain Injury Alliance for a Full day of skiing at Breckenridge Ski Resort

Date/Time: Wednesday March 29th and Wednesday April 12

8:30 am Equipment fitting at BOEC

9 am -3:30 pm Instruction

Lunch 12pm – 1pm (Bring your own lunch or buy from the resort)

Registration is limited to 6 BIAC participants per day. We will need you to register and turn in all paper work at least 2 weeks prior to Ski Day.

Conquer those winter blues! All beginners, intermediate or advanced skiers welcome. Instruction through qualified and experienced adaptive instructors whose goal is to “change lives one ski day at a time.”

Transportation:

Assess-a-ride, RTD, your car,

Ride w/BIAC from Mammoth Parking lot : Meet at 7am and be back at the lot around 5:30pm

If riding with BIAC contact Michael to coordinate:

Michael@BIAColorado.org
720-907-1455

If you would prefer to pay by check, or if you have any questions, please contact Michael Zavala at 720.907.1455

Event Information
Please select which program you would like to register for:*
- BOEC Full day Skiing Event – March 29, 2023 – $200 (3 spots left)
- BOEC Full day Skiing Event – April 12, 2023 – $200 (2 spots left)
Which activity would you like to participate in?*
- Skiing (stand, sit, 3 tracking)
- Snowboarding
- Cross Country Skiing
- Snowshoeing
- Sit Ski (Bi Ski, Mono Ski, Etc)
Do you have experience in the activity you selected?*
- Yes
- No
Personal Information
What is your connection to brain injury? (Person filling out form)*
- Survivor of BI
- Spouse of BI Survivor
- BI Professional
- Parent of BI Survivor
- Other Family of BI Survivor
- General Supporter of BI
- Child of BI Survivor
- Friend of BI Survivor
Are you a spouse, family member, friend, or BI professional that will be filling this application out for a BI Survivor to participate in the program?
- Yes, I am a spouse, friend, family member, or BI professional filling out this application for a BI survivor
- No, I am a BI survivor registering myself to participate.
Participant Name*
First Last
Participant Date Of Birth*
MM slash DD slash YYYY
Participant Height*
Participant Weight*
Participant Mailing Address*
Street Address Address Line 2 City State ZIP Code
Participant Phone*
Participant Phone Type*
- Home
- Cell
- Work
Participant Email*
Participant Gender
- Female
- Male
Participant Race/Ethnicity
Other Race/Enthicity
Primary Language of Participant*
- English
- Spanish
Name of Family/Friend Registering Participant
First Last
Phone of Family/Friend Registering Participant
E-Mail of Family/Friend Registering Participant
Name of Provider/Professional Registering Participant
First Last
Provider/Professional Organization or Company
Phone of Provider/Professional Registering Participant
E-Mail of Provider/Professional Registering Participant
Is the caregiver, family, or friend listed above a good emergency contact?
- Yes
- No
Emergency Contact*
First Last
Relationship*
Phone Number*
Phone Type*
- Home
- Cell
- Work
Medical Information
In this next section, we need to learn a little more about the event that caused the brain injury. If you don’t know the specific answer to a question, do your best to answer it as accurately as you can. Date approximations or guesses are ok.
Click the “Add injury” button to get started.

Survivor Injury Information

Date of Injury	Cause of Injury	Actions

There are no Injuries.

How does your brain injury affect you?*
Does the participant have seizures?*
- Yes
- No
Seizure Frequency
Seizure Type
Date of last seizure
MM slash DD slash YYYY
Seizure Triggers
Can the participant tell if seizure is going to occur?
- Yes
- No
Can Participant self-administer medications needed during activities?
- Yes
- No
Additional Information
Is there anything else that we need to know or you would like to tell us?
Newsletter
- I would like to receive the Brain Injury Alliance of Colorado’s Newsletter
Payment
Admin Code
Credit Card
Card Details
Cardholder Name
Would you like to add $3 to your registration to cover credit card processing fees?
- Yes, I would like to offset the CC processing fees
- No optional fee, thanks
Billing Name
First Last
Billing Address
Street Address City State / Province / Region ZIP / Postal Code
Admin code discount
Price:
Total
$ 0.00
Product Name
Hidden field to fix the correct amount.
Click here to read our Privacy Practices
I have read and agree to BIAC's Privacy Practices*
- Yes
I acknowledge and approve this information to be shared with staff and volunteers of BOEC at Breckenridge, BIAC's partner for this event.*
- Yes
Name
This field is for validation purposes and should be left unchanged.

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Adaptive Skiing Breckenridge Outdoor Education Center (BOEC)

Event Information

Personal Information

Medical Information

Additional Information

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