ACCESS of Wilmington, Inc.

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2025 Fun on the Water with ACCESS Play & Ocean Cure July 14th - 18th. If you have not reviewed the details for the week, please do so prior to completing registration by visiting our website accessilm.org/play
Participant Name: *
Participant Age: *
Primary & Secondary Diagnosis: *
Please note additional information staff should know regarding the participant participating in water activities:

Please use the space below if needed for additional ACCESS participants. Please do not register siblings or family members that do not qualify for ACCESS programming.
Participant Name (2):
Participant Age (2):
Primary & Secondary Diagnosis (2):
Please note additional information staff should know regarding the participant participating in water activities (2):

Participant Name (3):
Participant Age (3):
Primary & Secondary Diagnosis (3):
Please note additional information staff should know regarding the participant participating in water activities (3):

Parent/Guardian/Emergency Contact Information
Name: *
Phone Number: *
Email Address: *
Preferred method of contact to confirm sessions: *	Email Text Call

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