LA Chargers Team Registration

First Name(Required)

Last Name(Required)

Gender(Required)

Date of Birth(Required)

Email(Required)

Cell Phone(Required)

Emergency Contact Name(Required)

Emergency Contact Phone(Required)

Please describe your disability

If your assistive device was not listed, please describe your device below.(Required)

Current or Terminal Service Component:(Required)

Branch(Required)

Rank(Required)

Have you participated in any other adaptive or able bodied sports? If so, please explain.(Required)

If no, do you know your chair size so we can provide for you?(Required)

If you don't know your chair size, please provide height & weight

Do you have any concerns about passing or catching a football due to your disability?(Required)

All instructors are trained in working with athletes of varying ability. Please let us know how we can help you be successful.

How did you hear about the team/clinic?(Required)