Your name

Your email

Subject

Please select Disability Type
—Please choose an option—PhysicalCognitiveDevelopmentalOther
If 'Other', please enter more information

This information is to ensure that we may provide you with the best service possible:
Please describe the nature of your disability

Do you need the assistance of a Hoyer Lift for transference to the boat?
YesNo
Any adaptive equipment used on land? (ie wheelchair, walker, etc):

Age:
Weight:
Height:

Address:

Parent/Guardian Name (if applicable)
Parent Phone Number:
Parent email:
Emergency Contact:
Contact Phone #:

Are you a military veteran YesNo
Do you require a handicap van parking space YesNo
Will you be having a guest or a caretaker join you out on the water YesNo
(If so, please provide additional Release forms for them as well)

Please type your name as a signature:

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