Self Assessment Form

Personal details

Name of participant *

Email of participant *

Contact number of participant *

Date of birth of participant *

Name of Parent/Guardian (if applicable)

Email of Parent/Guardian (if applicable)

Contact number of Parent/Guardian (if applicable)

Are you completing this form for yourself? *

Yes
No

Your relationship *

If completing this form on behalf of someone else, please state your relationship to them.

Email *

If completing this form on behalf of someone else, please provide your email.

About you

What is the surfer's disability or medical condition? *

Is the surfer on any medication? *

Yes
No

Do they require this to be kept with them at the water's edge? *

Yes
No

Please provide further details: *

Does the surfer have any learning difficulties, cognitive impairments, or difficulty following instruction? *

Yes
No

Please briefly describe *

Does the surfer have any visual or hearing impairments? *

Yes
No

Please describe the level of vision or hearing below and whether any aids can be used in the water? *

Mobility

Is the surfer a wheelchair user? *

Yes
No

How does the surfer usually transfer from chair to chair or chair to floor? *

Is the surfer able to lay down flat on their front and lift their upper torso and head? *

Yes
No

Is the surfer able to grip with one or both hands? *

Yes
No

Is the surfer able to kneel? *

Yes
No

Is the surfer able to stand unassisted? *

Yes
No

Additional Information

Is the surfer able to swim 25 metres unaided? *

Yes
No

When in the water are they able to roll onto their back and keep their head above water? *

Yes
No

Has the surfer got any previous surfing experience? *

Yes
No

Please briefly describe *

Please use this box to provide any additional information which may be useful in enabling us to offer a safe and enjoyable activity:

Session Details

Please select 3 dates you are available in order of preference

Preferred visit date 1 *

Preferred visit date 2 *

Preferred visit date 3 *

Please indicate if you would prefer a morning or afternoon session: *

AM
PM

Which experience would you like to book? *

Additional Support Assessment Form

Personal details

About you

Mobility

Additional Information

Session Details