Registration: 2017 The LMCU Bridge Run - CAPTAINS

USER INFORMATION
Organization:
First Name:
Last Name:
Gender:
Male  Female  
Date of Birth (mm-dd-yyyy):
Email:
Confirm Email:
Phone (format: xxx-xxx-xxxx):
Address:
Address 2:
City:
State:
Zip:
Are there specific Angels you wish to team up with:
Yes  
No  
Shirt Size:
S  
M  
L  
XL  
2XL  
Primary diagnoses/injuries that resulted in your disability & any other pertinent information:
How long have you had your disability:
Since birth  More than 1 year ago  Less than 1 year  
Type of assistive device used:
None needed  Cane  Crutches  Walker  Wheelchair  
Ability to use a wheelchair:
None needed  Independent Manual  Independent Electric  Unable  
Transfer ability:
Independent  Requires Min Assist  Mod Assist  Max Assist  
History of seizures:
Yes  No  
Are you continent:
Yes  No  
Would you require any special feeding during the race:
Yes  No  
Height:
Weight:
Person Completing Registration - First/Last Name:
Relationship to Captain:
Self  Parent  Guardian  Friend  
Enter the Security Code:
I agree to the terms and conditions:
Read Terms & Conditions

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