REGISTRATION FORM
Please complete the form below to register to our Programs.
Please select the program or programs you are interested in:
*
Liquid Board riders
Liquid Free riders
A drop in the Ocean (Mental Wellbeing)
Liquid Academy
Water wheels
Surf Camp
Volunteer Tuesdays (Community groups only)
AS Open
Liquid Big Brother/ Big sister
ABOUT YOU
Name of GUARDIAN
*
First Name
Last Name
Phone Number of GUARDIAN
*
-
Area Code
Phone Number
Email of GUARDIAN
example@example.com
ABOUT THE PARTICIPANT
What is your relationship to the PARTICIPANT?
*
son
daughter
niece
nephew
grandson
granddaughter
cousin
family friend
distant relative
caregiver
Name of PARTICIPANT
*
First Name
Last Name
Age of PARTICIPANT
*
in years
Gender of PARTICIPANT
*
Male
Female
Diagnosis of PARTICIPANT
*
Is the PARTICIPANT water confident?
*
YES
NO
SOMETIMES
Has the PARTICIPANT surfed before?
*
YES
NO
Has the PARTICIPANT been to any Liquid Therapy programs before?
*
YES
NO
Any Other Info You Wish To Add:
Submit
Should be Empty:
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