Advanced Recreation Therapy Registration Form

Advanced Recreation Therapy Registration Form
Please select with event/date you are registering for:*

Adaptive Surfing @ Horseneck Beach, Friday, September 5, 2025

Participant Information:
Full Name*

First NameLast Name
DOB*

MonthDayYear
Date
What gender do you identify as?(Collected for grant purposes only)*

FemaleMaleNonbinaryTransgenderPrefer Not to Say
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
E-mail*
All JTF communication for programming will be via email!
Level of Injury
Have you tried surfing post SCI?*

YesNo
Have you tried water skiing post SCI?

YesNo

Emergency Contact Information