Liquid Therapy Membership Registration Form

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? *
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? *
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:

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REGISTRATION FORM