Our summer season for 2024 is now fully booked. Please apply for our waiting list below.
I understand that I am on a waiting list only
Yes
ABOUT YOU AND THE PARTICIPANT
Please note all information given will be treated with the utmost confidentiality and will be stored in line with Ireland's National GDPR guidelines.
Name of Caregiver
*
First Name
Last Name
Contact Number of Caregiver
*
Email of Caregiver
*
example@example.com
What is your relationship to the participant?
*
Is this your first Liquid Therapy Experience
*
Please Select
Yes
No
Name of Participant
*
First Name
Last Name
Gender
*
Please Select
Male
Female
Other
Age of participant (minimum 6 and maximum 16)
*
Please Select
6
7
8
9
10
11
12
13
14
15
16
Diagnosis of Participant (if no diagnosis please put N/A)
*
How does the participant communicate?
*
Please Select
Speaking
At times not speaking
Currently not speaking
Other
Does the PARTICIPANT use a mobility aid?
*
Please Select
Manual Wheelchair
Powered Wheelchair
Walking Aid
None
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