The following intake form will take no longer than 5 minutes to complete and is required in order to register your interest for upcoming WOW programs.

At WOW we have a range of different program types and by completing this form it will allow us to understand what program you are eligible for.

If you have more questions about our sessions please give us a ring on 0459041832, check out website www.foundationwow.org or shoot us an email at info@foundationwow.org

First Name

Last Name

Email

Please re-enter Email

Gender

Mobile Phone

Please enter your phone number starting with +61 for example +61400000000. Your number may be used to send you updated about the program

Date of Birth (DD/MM/YYYY)

Please click on the calendar to add your birth date.

Age

Age Check

Age OKNot OK

Street

Suburb

State

Postcode

Thank you for registering your interest in our programs. Unfortunately, WOW does not provide programs for participants under the age of 12. If you would like to know more about our programs please head to www.foundationwow.org/surf-therapy.

If you would like to speak with someone from WOW, please email us at info@foundationwow.org

Are you able to swim 50m?

YesNo

Are you fit enough to take part in a 1.5 hour surf lesson?

YesNo

Are you able to participate in group based discussions regarding mental health?

YesNo

Referral Code

Have you been given a program referral code to use? We provide codes to participants who are completing a program with a community partner and will take them directly to the program they are looking for.

Have you been given a referral code to use?

YesNo

Referral Code

Program Code

Program Selection

Program

Referring Program ID

If you don't see any options in the drop down, please go back and select 'No', as the requested program may not be available at this time.

Program Selection

Available Program Options - click this drop down to view upcoming programs

Program ID

Capacity

Number of Gender other than Male

Program Type

Number of Available Spaces

Beach Locations

Program Description

-

This program is currently full.

You will be placed on a waitlist and you will be contacted if there is an availability.

Please select the appropriate answer

I can see program(s) in the drop-down and have selected oneI can see program(s) in the drop-down but no option is suitable for meI can't see any program(s) in the drop-down above

Program Choice ID

Why are none of the available programs suitable for you?

Would you like to be put on a waitlist based on the information you've provided?

YesNo

Waitlist Program ID

Option ID

What is your preferred beach location?

Thank you for providing us with your details and we are sorry to hear that we don't currently have a suitable program available for you.

As we are a charity, our program availability depends on a number of factors including community need and funding available to deliver programs. If you have further questions, please refer to FAQs page on our website.

Please visit our website at www.foundationwow.org for our current list of program locations or follow us on Instagram @foundationwow for the latest news on new locations.

If you would like to speak with someone from WOW, please email us on info@foundationwow.org

Do you have any prior injuries which may affect your ability to partake in a 1.5 hour surf lesson? (e.g. shoulder dislocation or knee reconstruction).

Yes No

Please provide details about your injury

Are you on any medication? If yes, give details

YesNo

Please give details about your medication

Is there any other information you need to notify us about regarding your situation? This would include any potential triggers we should be aware of.

What are you hoping to get out of this program?

Learn about surfingBetter manage my mental healthConnect with othersOther

Please let us know what you are hoping to get out of this program

Please provide the name of your Emergency contact

Please provide the phone number of your Emergency contact

Please let us know your relationship with your Emergency contact

Are you referring someone else?

YesNo

Your name

Your relationship to the participant

Your contact number

Your email

COVID-19 Conditions of Participation

I agree, that if prior to commencement of or during the program, I have flu-like symptoms, I will not participate in the WOW program.

Yes

I will abide by any Public Health Orders in my region.

Yes

Acknowledgement

By ticking the boxes below, you acknowledge, understand and agree to their terms, either on your behalf, or on behalf of a minor that you are the parent, guardian or supervisor of.

I have read and understand WOW's Privacy Policy and Terms & Conditions

Yes

I agree and consent to the Liability Waiver and its terms

Yes

I agree and consent to the Media Waiver and its terms

Yes

I'd like to keep up to date with the latest news and information from WOW

Yes

Instagram	Facebook
Website	Workplace
Friends or Family	GP
Psychologist	Case Manager / Case Worker
Psychiatrist	Counsellor
Teacher	Other

Referral Code

Program Selection

Program Selection

COVID-19 Conditions of Participation

Acknowledgement

Thank you! Please press the 'Submit' button below.