Krazy Kosci Klimb : Lead Participants EOI

Personal Details

First Name *

Last Name *

YEAR of Birth *

Suburb *

State

Phone number *

Email *

What's the best way for us to contact you? *

How did you hear about The Krazy Kosci Klimb? *

What's your motivation to take on the challenge? *

Are you client of Cerebral Palsy Alliance? *

If so - what CPA centre do you attend?

Who is your CPA therapist?

What do you identify as your primary disability? *

Please provide more information about your primary disability *

Do you have any other disabilities or medical / health conditions? *

If yes, please specify your other disabilities or medical / health conditions:

Do you rely on a mobility aid?

If other, please specify

Have you done the climb before?

Yes
No

What distance of the climb do you expect to walk, if at all? (all-terrain wheelchairs will be provided for individuals not walking the full distance)

18km - Walk the full distance of the summit without a wheelchair
9km - Walk half the distance of the summit without a wheelchair and complete the remaining distance with a wheelchair
5km - Walk 5km without a wheelchair and complete the remaining distance with a wheelchair
I don't expect to walk - I will use the wheelchair the whole distance

Which family / support people would join you on your journey? Maximum 3 people, minimum age 10; the climb is not suitable for siblings younger *

Fundraising

Fundraising is a component of the Krazy Kosci Klimb. Funds raised support the Health and Wellness Program at Cerebral Palsy Alliance.

Please list some of your fundraising ideas you would use with your team *

Do you feel you have a good understanding of what is involved in the Krazy Kosci Klimb? *

Yes
No, I would like some more information by email
No, I would like a phone call to learn more

By clicking “Submit”, I confirm that:

The information provided in this EOI form is true, accurate and complete to the best of my knowledge;
I understand that my personal information will be collected and used in accordance with Krazy Kosci Klimb : Privacy and Cerebral Palsy Alliance's Privacy Policy

Lead Participant Expression of Interest

Personal Details

Fundraising

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