Surf Therapy Camp at Huntington Beach – June 3, 2023

Surf Session Arrival: *9:00AM Arrival

Guardian/Chaperone Name *

Phone: *

Email: *

Does your child qualify for free or reduced lunch? *yesno

Athlete Name (First and Last): *

Athlete Date of Birth: *

Athlete Age: *

Is this your athlete's first time at an Urban Surf 4 Kids camp?*yesno

Youth Home Situation (Choose one): *Foster YouthAt-risk YouthGroup Home ResidentKinship YouthAdopted Youth

Please describe what kind of childhood trauma your child has experienced that would qualify them for our programs if they have not experienced foster care:

Has youth experienced juvenile hall/probation? *yesno

Describe:

Has youth experienced homelessness in the last 1-5 years? *yesno

Is youth a survivor of abuse, abandonment, neglect? *yesno

Please describe trauma and any important facts we should know: (e.g. Past trauma with water or loud noises, prefers a female mentor, shuts down when hearing yelling, sensory sensitive, does not like being touched, allergies flare up in summertime) *

Please describe any special needs your child has: (e.g. high-functioning autism, PTSD, ADHD, hearing impaired, fetal alcohol syndrome, asthma, visual processing disorder, etc.)

List any food allergies::

Will your child be taking medication during the event? *yesno

If yes, please list medication(s):

Has your child experienced any recent changes in behavior and/or mood? *yesno

If yes, please describe:

Athlete swim knowledge: *beginnerintermediateadvanced

Athlete surf knowledge: *never surfed beforeplayed on a boogie boardsurfed 1-3 timessurfed 4-10 times

Athlete ocean experience: *first time to the oceanplayed at the beach but not in the watercomfortable in the ocean/water

How many times have you joined an Urban Surf 4 Kids surf camp? *

Ethnicity (Choose one): *Native/American IndianAsian/ Asian AmericanBlack/African AmericanNative Hawaiian/Pacific IslanderCaucasian/WhiteLatinx/HispanicMulti-Racial (2+ races/ethnicities)Additional/Other ethnicity (please specify)

Other Ethnicity:

Athlete's preferred pronouns (ex: She/Her, He/Him, They/Them)

Does athlete have a gender preference for a surf partner?

For wetsuit purposes, what is your child's gender and approximate height / weight?

Gender: MaleFemaleTransgenderNonbinaryOther (please specify)

Other:

Athlete Height:

Athlete Weight:

Address *

City *

State *

Zip *

Including you and your youth, how many total attendees will you have at our event?
*please note that due to catering limits, we will only be able to provide lunch to the athlete, 1 caregiver, and their plus-one *

Do you grant Urban Surf 4 Kids permission to to take photos and/or videos of your child for private, public, or media purposes? *yesno