Swim SIGN-UP 2019-2020

Yes U Can Swim Extension Program at UD

For People with Disabilities or Limited Ability

NOTICE - STARTS FEB. 19th, 2020, 7-8pm
SIGN-UP FORM
Join the Swimming Program? *

Yes No
A collaborative program between the University of Delaware and Yes U Can USA. Students assist people with limited mobility or disabilities to exercise in the pool one-on-one. There is NO FEE for the 2019-2020 semesters.

When: Fall / Spring Semester
Sept 4, 2019 - May 20, 2020 | Wednesday Nights, 7 – 8 PM

Where:
University of Delaware, Bob Carpenter Sport Center (Little Bob)*
Outdoor Recreation Resource Center, Rm. 005
26 N. College Ave., Newark, DE 19713

*The center is at the back of the parking lot across from McDowell.
First Name *
Last Name *

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone *
E-mail *
To better serve you, please check boxes that apply. This information will help us design future programs.
Condition *

Amputee‎ Brain Injury‎ Cancer Cerebellar Ataxia Cerebral Palsy‎ CIDP Fibromyalgia‎ Hearing Impaired‎ Metal Poisoning MS‎ Paraplegia‎ Parkinson’s‎ Quadriplegia‎ Rheumatoid Arthritis‎ Sarcoidosis Spinal Fusion Stroke‎ Visually Impaired‎
Gender *

Male‎ Female
Age *

18 - 19‎ 20 - 29‎ 30 - 39‎ 40 - 49 50 - 59‎ 60 - 69‎ 70 - 79‎ 80 - 89‎
Are you a Military Veteran? *

Yes No
Are you a member of Colonial Paralyzed Veterans of America? *

Yes No
Do you use any mobility aides? *

cane‎ walker‎ manual wheelchair‎ power wheelchair‎ no, I do not‎
Need assistance to park your car?

Please indicate if you need assistance parking your car. Parking is limited. Participants can drive and park in front of the CSB (Little Bob) entrance and a student will greet you and park your car. They will place a temporary UD Handicap Placard in your car and park in a designated parking space.
Do you need assistance parking your car? If "yes," enter make and color of car below. *

Yes, I do No, I do not
Make of car?
Color of car?
Optional Message
Optional Message
Permission Request

For the exercise program to run effectively and safely, we need to share your information on this form with the exercise program's student volunteers who will assist you.
Permission to share your information? *

Yes, you may share No, you may not share
Programs are currenlty free.

Donations are greatly appreciated!
By submitting this sign-up form, you elect to participate in this Yes U Can program and you agree to allow the Yes U Can Corp. to use photographs and/or video that may be taken of these sessions for marketing purposes, e.g. website, Facebook, brochures, etc.
Website: YESUCANUSA.ORG
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