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Adaptive Surfing Registration Form
Midway Beach, Gisborne
Sunday 13th February 2022 9am Start
Any Queries/Info contact Lou 020-40809069 or email
louise@parafedgisborne.co.nz
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Name
*
Your answer
Age
*
Your answer
Disability and/or Medical Conditions
*
Your answer
Mobility Aids
*
Wheelchair
Powerchair
Crutches/Frames
None
Other:
Phone Number
*
Your answer
Emergency Contact & Ph no.
*
Your answer
Do you require a support person?
*
Yes
No
Do you have any special dietary requirements?
*
Your answer
Disclaimer
*
Yes, I agree
No, i do not agree
Required
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