Athlete Disability Classification Form
Please complete this form to provide information required for athlete disability classification. All information will be kept confidential and used solely for classification purposes.
Athlete Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Non-binary
Prefer not to say
Contact Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Sport
*
Please Select
Athletics
Swimming
Wheelchair Basketball
Table Tennis
Cycling
Other
Type of Disability
*
Physical Impairment
Visual Impairment
Intellectual Impairment
Other
Description of Disability (please specify diagnosis and relevant details)
*
Upload Medical Documentation (if available)
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Functional Assessment Results
*
Rows
Not Limited
Mildly Limited
Moderately Limited
Severely Limited
Range of Motion
1
2
3
4
Muscle Strength
5
6
7
8
Coordination
9
10
11
12
Balance
13
14
15
16
Vision
17
18
19
20
Cognitive Function
21
22
23
24
Classification Outcome
*
Please Select
Eligible
Not Eligible
Provisional
Needs Further Assessment
Additional Comments
Assessor Name
*
First Name
Last Name
Date of Assessment
*
-
Month
-
Day
Year
Date
Signature of Athlete or Guardian
*
Submit Classification
Submit Classification
Should be Empty: