Participant Clinic Intake

Please note by completing this form you agree that you will not be under the influence of any mind altering medications, drugs, alcohol, marijuana, or any other substances that would impair your ability to participate in the activities you have signed up to participate in. Also by completing this form you agree to participate in all of the activities of the event you have signed up for to the best of your abilities and are allowed to barring any restrictions that must be kept for the safety of you, your family members, the staff, volunteers and partners of AmpSurf conducting the events.
You will be taken to the “Welcome to the family Page/Fundraising” page when you click the submit button. this means your form was submitted successfully.

AmpSurf 2019 Clinic intake form

* Which Chapter location did you sign up to surf at? Select a chapter California New England New York Oregon

This is the chapter that the participant has signed up to surf with. i.e York Beach, ME would be the New England Chapter.

* Participant or Family member Select one I am the Participant Family Member

Family Members -Please give us the first and last name of the participant you are attending the clinic with.

We encourage all family members to surf as well. Please complete all the information on the this form to help us make sure you have a great time in the water as well.

* First Name

* Last Name

* Email

* Phone Number

* Address

* City

* State

* Zip Code

* Describe your disability.

* Do you use a wheelchair? No Yes

So, we can make sure we have a beach wheelchair available for you.

Please check all that apply (if applicable)

Military Veteran

Police

Fire Fighter

* Height

* Weight

* Gender Female Male

* Age

* Emergency Contact Name

* Emergency Contact Phone #

Please note by completing this form you agree that you will not be under the influence of any mind altering medications, drugs, alcohol, Marijuana, or any other substances that would impair your ability to participate in the activities you have signed up to participate in. Also by completing this form you agree to participate in all of the activities of the event you have signed up for to the best of your abilities and are allowed to barring any restrictions that must be kept for the safety of you, your family members, the staff, volunteers and partners of AmpSurf conducting the events.

You will be taken to the “Welcome to the family Page/Fundraising” page when you click the submit button. this means your form was submitted successfully.