Just a page to test content Testing-AmpSurf 2019 Clinic intake form * Which Chapter location did you sign up to surf at? Select a chapter California New England New York This is the chapter that the participant has signed up to surf with. i.e York Beach, ME would be the New England Chapter. Clinics in California April 13th May 18th June 8th July 6th Aug. 1-4th Aug. 10th Sept. 7th Oct. 5th Check off the clinic dates you signed up for in California. Please check your Deposit receipt to make sure you select the correct dates. Clinics in New England June 8th June 22nd July 20th Aug. 3rd Aug 17th Sept. 7th Sept. 14th Check off the clinic dates you signed up for in New England. Please check your Deposit receipt to make sure you select the correct dates. Clinics in New York area June 29th Aug. 17th Sept. 14th Check off the clinic dates you signed up for in New York. Please check your Deposit receipt to make sure you select the correct dates. * 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 #
