Waitlist Registration - Miami Beach, FL

1 Start 2 Waiver 3 Confirm 4 Complete

Parent/Primary Contact Information

First Name *

Last Name *

Suffix

Street Address *

Street Address Line 2

City *

State *

Postal Code *

Country *

Mobile Phone Number *

Important and time sensitive camp updates can be sent directly to the number provided using SMS

Email *

Are you or your spouse/partner an active member of the military?

Yes

Service Branch

* Proof of status may be requested at check-in

Participant Information

Parent/Primary Contact Email *

Please ensure the email address indicated matches the Parent/Primary Contact above

First Name *

Last Name *

Suffix

Birth Date *

Month

Day

Year

Gender *

Weight (lbs) *

T-Shirt Size *

Event *

Participated in a Surfers Healing event before? *

Yes

Registering Additional Campers?

If you wish to register additional campers (up to 3) please specify the required number and proceed. Please note that although we welcome the entire family to enjoy a day at the beach together, the surfing component of our camps is reserved exclusively for individuals with autism. (Our insurance does not cover neurotypical participants).

Number of Additional Campers

2nd Participant Information

Participant is on the autism spectrum? *

Yes

Sorry, you may only register additional participants who are on the autism spectrum.

Parent/Primary Contact Email *

Please ensure the email address indicated matches the Parent/Primary Contact above

First Name *

Last Name *

Suffix

Birth Date *

Month

Day

Year

Gender *

Weight (lbs) *

T-Shirt Size *

Event *

Participated in a Surfers Healing event before? *

Yes

3rd Participant Information

Participant is on the autism spectrum? *

Yes

Sorry, you may only register additional participants who are on the autism spectrum.

Parent/Primary Contact Email *

Please ensure the email address indicated matches the Parent/Primary Contact above

First Name *

Last Name *

Name Suffix

Birth Date *

Month

Day

Year

Gender *

Weight (lbs) *

T-Shirt Size *

Event *

Participated in a Surfers Healing event before? *

Yes

4th Participant Information

Parent/Primary Contact Email *

Please ensure the email address indicated matches the Parent/Primary Contact above

Participant is on the autism spectrum? *

Yes

Sorry, you may only register additional participants who are on the autism spectrum.

First Name *

Last Name *

Suffix

Birth Date *

Month

Day

Year

Gender *

Weight (lbs) *

T-Shirt Size *

Event *

Participated in a Surfers Healing event before? *

Yes

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