AAAT Registration

Name:

Address:

Email:

Cell Phone:

Preferred contact method:
EmailCell PhoneEither

Are you completing the form for yourself or someone else? (If someone else, please provide their name, address, email, cell phone above and add your contact information in the comments box below.)
For MyselfFor Someone Else

When would you like to go on an adaptive trip to Switzerland? (Trips are 11 days long).

Type of Disability:
Spinal Cord InjuryBrain InjuryStrokeOther

Additional Disability Information (Date of incident? Complete or incomplete spinal injury? Level of injury? :

Do you own adaptive equipment to travel on rough, outdoor terrain? YesNo

If applicable, describe your adaptive equipment

If applicable, upload a photo of your adaptive equipment

What kind of help do you need with activities of daily living? NoneSome assistance with setting up my clothing/hygiene routinesAssistance with transfersAssistance with bowel careAssistance with bladder careAssistance with swallowing/dysphagia diet or clearing secretionsAssistance with IADLs, cognitive reasoning

What kind of help do you need with mobility? NoneCaneWalkerWheelchairPower wheelchair

Do you have any active pressure ulcers? YesNo

Please list your current medications

Do you need financial assistance to participate in this trip? People who qualify for assistance must be a U.S. citizen AND EITHER

• receiving Medicaid OR

• a fully disabled veteran of the US armed forces OR

• have an annual household income of less than 3x the federal poverty level on most recent tax return

YesNo

Please provide proof of your status (Medicaid card, physicians letter, disabled veteran’s letter, or tax return).

Do you have any other questions or comments?