Liquid Therapy Membership Registration Form

REGISTRATION FORM

Please complete the form below to register your interest in our Programs. Please note that due to Covid 19 and implemented social distancing we have had to apply three safeguards: 1. Participants must be aged between 8 and 16. 2. Participants must be able to move independently in the water. 3. Participants must be Able to independently follow instruction.
The following programs have availability. Please select the 2021 program or programs you are interested in: *

All programs are full for 2021. Please monitor our website and social media for future opportunities
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 (minimum 8 year for the 2021 season due to Covid-19) *
in years
Gender of PARTICIPANT *

Male Female
Diagnosis of PARTICIPANT(S) *
Is the PARTICIPANT water confident? *
Can the PARTICIPANT move independently in the water?

Yes No
Has the PARTICIPANT surfed before? *
Has the PARTICIPANT been to any Liquid Therapy programs before? *
Any Other Info You Wish To Add (e.g. Additional diagnosis/ whether you'd like no pictures taken):
Should be Empty:

REGISTRATION FORM