Liquid Therapy Membership Registration Form

REGISTRATION FORM

Please complete the form below to register to our Programs.
Please select the 2021 program or programs you are interested in: *

A drop in the Ocean (Mental Wellbeing) Liquid Board riders (June, July and August) Liquid Surf Academy (July and August)
ABOUT YOU
Name of GUARDIAN *

First Name Last Name
Contact Number of GUARDIAN *

Area Code Phone Number
Email of GUARDIAN
example@example.com
ABOUT THE PARTICIPANT
What is your relationship to the PARTICIPANT(S)? *
Name(s) of PARTICIPANT *

First Name Last Name
Age(s) of PARTICIPANT *
in years
Gender of PARTICIPANT *

Male Female
Diagnosis of PARTICIPANT(S) *
Is the PARTICIPANT water confident? *
Has the PARTICIPANT surfed before? *
Has the PARTICIPANT been to any Liquid Therapy programs before? *
Any Other Info You Wish To Add:
Should be Empty:

REGISTRATION FORM