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KOA x AccesSurf Participant Form
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First Name
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Last Name
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Mobile Phone Number
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Emergency Contact Name
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Emergency Contact Number
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Caregiver or Support Person Name
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Caregiver or Support Person Phone Number
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Do you have a medically diagnosed disability? If so, please select all that apply.
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What year were you born?
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Will this be your first time participating in a KOA x ASH Program? 
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T-Shirt Size
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Waiver and Release of Liability – Kahākūkahi x AccesSurf Hawaiʻi (ASH) Day at the Beach
Please sign on behalf of the children in your party. Provide their full names and separate with a comma for multiple children. Write "N/A" if no children.
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By typing your name, you accept the terms and conditions of the "On Camera Release, Release of Liability and Assumption of Risk" form for yourself and all other individuals listed in your party.
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Signed On (Todayʻs Date)
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