Capital Region FCA All Abilities Basketball Clinic

April 19th, 2025

Location Information

Location Name
Middleburgh Central High School
Address
291 Main Street, Middleburgh, NY, 12122 US
Directions
Google, Bing, MapQuest

Participant Enrollment

Attendee Age Range*

Minor (17 & under)
Adult (18 & older) - Parent/Guardian Must Sign On My Behalf
Adult (18 & older) - Can Sign Of My Own Volition

Name*

Address*

Date of Birth*

Home Phone Number*

Cell Phone Number

Email*

Gender*

Male
Female

School*

T-Shirt Size*

Athlete Information

Name of athlete's disability:*

Please describe how this disability manifests:*

Sports/fitness activities in which the athlete has already participated or is currently participating*

What do you need us to know and understand about this camper?*

Does the athlete have any triggers?*

Are there any activities that can calm the athlete if they are feeling overwhelmed?*

Choose the best that applies. The athlete would best learn:*

In a typical setting for the athletes’s age group with no supports
In a typical setting for the child’s age group with a buddy who is:
- An adult - An older student - A peer
In a separate area with a trained teacher and a small group of other special needs students
A combination of the above. Please describe why you believe this to be your athletes's best learning setting selection

Does the athlete suffer from seizures?*

Yes
No

What other medical concerns should we know about?*

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