BOEC DAY

BOEC DAY

Enjoy a day out in the mountains with BOEC while they offer a couple of fun adaptive activities for you to join in! You have a choice between a relaxing day on the lake paddling and fishing or a fun filled day on the ROPES course with the wonderful staff at BOEC. Lunch will be provided by BOEC. Transportation is available but, at an extra cost and space is limited so please make accommodations sooner than later to ensure a spot.

If receiving transportation we will be leaving the Mammoth Parking lot by 8am to arrive at BOEC by 9:30am.

Time:
June 26th
9:30 a.m. to 3:00 p.m.

Location:
Brain Injury Alliance of Colorado
1325 S. Colorado Blvd., B300
Denver CO 80222

Who:
Adults age 18 and older

Cost:
$55

$10 extra for transportation

Questions?
Contact Michael Zavala: 720-907-1455 or michael@biacolorado.org

Registration\

BOEC Day Registration

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 Day – June 26th – $55.00 (7 spots left)
We plan to arrive at BOEC at 9:30am for a fun day on the lake or suspended in the ropes course.
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 the one that will be participating in the program?
- Yes, I am the participant
- No, I am registering for a survivor 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
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?*
Secondary Diagnosis
Effect of Secondary Diagnosis on Survivor
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
Seizure Protocol
Medications
Please Provide: Name of Medication, Dose, Frequency, Effects, and Side Effects
Can Participant self-administer medications needed during activities?
- Yes
- No
Please provide more information about medication administration requirments
Mobility*
- Walks Independently
- Cane
- Crutches
- Walker
- Manual Wheelchair
- Electric Wheelchair
Communication*
- Verbal
- Non-Verbal
- ASL
Hearing
- Deafness – Right
- Deafness – Left
- Hearing Aid – Right
- Hearing Aid – Left
- Cochlear Implant
Select all that apply
Vision
Please describe any vision issues the participant may have
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 at Breckenridge Outdoor Education Center (BOEC) in Breckenridge, BIAC's partner for this event.*
- Yes
Name
This field is for validation purposes and should be left unchanged.

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