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About IncredAble Adaptive MMA
Jackson Wink
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About IncredAble Adaptive MMA
Jackson Wink
Financial Data
Contact Us

Donate Now

Register for Classes

Empower yourself or a loved one. By filling out this form you agree to our waiver.

Student Information

We apologize for inconvenience, but we are currently not accepting any applications for anyone over the age of 21 years old and parents or guardians are required to stay in the gym with their child/student during lessons.

Name(Required)

First Last

Email(Required)

Enter Email Confirm Email

Primary Phone #(Required)

Secondary Phone #

Preferred Contact Method(Required)

Email

Phone

Both

Gender(Required)

Male

Female

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Is the participant able to stand?

Yes

No

Sit-Down Students Information

Shoulder Pain(Required)

No

Yes

Discomfort

Will rolling onto your shoulders cause pain to your back or shoulders?

Wheelchair Independency(Required)

No

Yes

Discomfort

Using arm strength, can you push your own wheelchair independently?

Do you have Harrington Rods or a shunt?(Required)

No

Yes

Grip Strength(Required)

No

Yes

Do you have the ability to maintain grip strength in your hands?

Spinal Cord Injury Level(Required)

Any Other Concerns?

Measurements

Date of Birth(Required)

Month

Day

Year

Height(Required)

Weight(Required)

Emergency Contact

Name(Required)

Email(Required)

Primary Phone #(Required)

Secondary Phone #

Participating in a school program?(Required)

No

Yes

Name of School(Required)

Teacher Name(Required)

Medical Information

Do you have medical clearance?

Yes

Does the participant have medical clearance from his/her physician to engage in physical activity?

Description of Disability

Describe the participant's disability.

Effects of Disability

What major life function(s) are affected?

Activity Level

What is the participant's general activity and energy level?

Medications

List any medications the participant is currently taking.

Seizure Information

Has the student experienced a seizure within the past year? If so, please indicate the approximate date of last seizure

Allergies

Indicate the participant's food and medication allergies. Is an Epinephrine Pen used to treat allergies?

Activity Limits

Does the participant need a limit on their activity for any reason?

Injuries

Please list any existing injuries or other pertinent information.

Physician's Name

Physician's Phone #

Ability to Sense Cold(Required)

Normal

Impaired

Unable

Comprehension(Required)

Normal

Impaired

Unable

Hearing/Vision Level(Required)

Normal

Impaired

Unable

Verbal Communications(Required)

Normal

Impaired

Unable

Participation Preferences

Days Able to Attend Class

Monday

Tuesday

Wednesday

Thursday

Friday

Class Types Preferred

One-On-One

In-Person

One-On-One Preferred Times

List any day and time preferences between 1 PM to 4 PM on weekdays.

Would it help the participant to come and see the facility first and meet us?(Required)

No

Yes

Signature

301 Dr Martin Luther King Jr AVE NE
Albuquerque, New Mexico 87102

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