Advanced Recreation Therapy Registration Form
Please select with event/date you are registering for:
*
Adaptive Kayaking @ Duxbury Bay, Tuesday, June 23, 2026
Adaptive Surfing @ Horseneck Beach, Friday, July 10, 2026
Adaptive Waterskiing @ Southbury, CT, Friday, July 24, 2026
Adaptive Surfing @ Horseneck Beach, Friday, August 14, 2026
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Participant Information:
Full Name
*
First Name
Last Name
DOB
*
-
Month
-
Day
Year
Date
What gender do you identify as?(Collected for grant purposes only)
*
Female
Male
Nonbinary
Transgender
Prefer Not to Say
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Format: (000) 000-0000.
E-mail
*
All JTF communication for programming will be via email!
Level of Injury
Have you tried surfing post SCI?
*
Yes
No
Have you tried water skiing post SCI?
*
Yes
No
Have you tried kayaking post SCI?
*
Yes
No
What is your goal for participating in this event?
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Emergency Contact Information
In case of emergency, who should we contact?
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to Participant
*
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How did you hear about this event?
*
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Registration Fee
*
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Registration
$
25.00
Quantity
1
2
3
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Please be aware that registration fees are nonrefundable.
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