Student Name(Required) First Last Lead Instructor(Required)Instructor Assists Names, if more than one instructor was presentLesson Date(Required) MM slash DD slash YYYY Accommodations Requested(Required) Mobility Hearing Visual Cognitive Accommodations Needed/Used during Lesson(Required) Mobility Hearing Visual Cognitive Safety/Medically Relevant Information(Required)This field is hidden when viewing the formDiagnosis/Condition(Required)Acquired Brian Injury (ABI)Alzheimer's DiseaseAmputationAmyotrophic Lateral Sclerosis (ALS, Lou Gehrig's Disease)AphasiaApraxiaArthritisArthrogryposis Multiplex Congenital (AMC)AsthmaAttention Deficit/Hyperactivity Disorder (ADD/ADHD)Autism Spectrum Disorder (ASD)BurnsCancerCerebral Palsy (CP)Cerebrovascular Accident (CVA or Stroke)Charcot-Marie-Tooth Disease (CMT)Chronic Traumatic Ecephalopathy (CTE)Congenital Anomalies of the Hip, Leg, or FootCystic FibrosisDiabetesDown SyndromeDwarfismDysarthriaEmotional Behavior DisorderEpilepsy/Seizure DisorderFetal Alcohol Syndrome Disorder (FASD)Fragile X Syndrome (Martin-Bell Syndrome)Friedreich's AtaxiaGuillain-Barre SyndromeHearing-Related DiagnosisHuntingtons DiseaseIntellectual DisabilitiesLupusMultiple Sclerosis (MS)Muscular DystrophyMyastehnia GravisNon-Verbal Learning DisabilityParkinson's DiseasePoliomyelitisPost-Polio SyndromePost-Traumatic Stress Disorder (PTSD)Rett SyndromeSensory Processing DisorderSpina BifidaSpinal Cord Injury (SCI)Spinal Curvature DisordersSpinal Muscular AtrophyTraumatic Brain Inquiry (TBI)Trisomy 18 (Edwards Syndrome)TumorVascular DiseaseVision-Related Diagnosis (VI)OtherThis field is hidden when viewing the formAdditional Diagnosis/ConditionAcquired Brian Injury (ABI)Alzheimer's DiseaseAmputationAmyotrophic Lateral Sclerosis (ALS, Lou Gehrig's Disease)AphasiaApraxiaArthritisArthrogryposis Multiplex Congenital (AMC)AsthmaAttention Deficit/Hyperactivity Disorder (ADD/ADHD)Autism Spectrum Disorder (ASD)BurnsCancerCerebral Palsy (CP)Cerebrovascular Accident (CVA or Stroke)Charcot-Marie-Tooth Disease (CMT)Chronic Traumatic Ecephalopathy (CTE)Congenital Anomalies of the Hip, Leg, or FootCystic FibrosisDiabetesDown SyndromeDwarfismDysarthriaEmotional Behavior DisorderEpilepsy/Seizure DisorderFetal Alcohol Syndrome Disorder (FASD)Fragile X Syndrome (Martin-Bell Syndrome)Friedreich's AtaxiaGuillain-Barre SyndromeHearing-Related DiagnosisHuntingtons DiseaseIntellectual DisabilitiesLupusMultiple Sclerosis (MS)Muscular DystrophyMyastehnia GravisNon-Verbal Learning DisabilityParkinson's DiseasePoliomyelitisPost-Polio SyndromePost-Traumatic Stress Disorder (PTSD)Rett SyndromeSensory Processing DisorderSpina BifidaSpinal Cord Injury (SCI)Spinal Curvature DisordersSpinal Muscular AtrophyTraumatic Brain Inquiry (TBI)Trisomy 18 (Edwards Syndrome)TumorVascular DiseaseVision-Related Diagnosis (VI)OtherEquipment Used(Required) Basic Ski equipment Basic Snowboard equipment Bamboo Hula Hoop T-bar Harness Tether(s) Tip-tether Standing Outriggers Slider/Glider Bi-ski Mono-ski Safety/lesson vests Select all that applyLifts/Terrain Used Ballroom Buttercup Easy Rider Vista Daisy Cascade MHX Stadium HRM Heather Canyon Clark Canyon Private Reserve Select all that applyTerrain Used(Required) Green Blue Black Off-Piste Gated Terrain Select all that applyWhat goals/tasks/skills were worked on during this lesson?(Required)Please list any successes and/or challenges from the lesson. How were challenges managed?(Required)Plan For Next LessonMood/Affect and Medical Information for Next Instructor/Assist(Required)Goals/Tasks/Skills(Required)Terrain(Required)
