Sign up Surfivor

Name

Surname

Email address

Street

Apartment / unit

City

Zip code

State

Date of Birth

Phone number

You want to sign up for which program? You want to sign up for which program? Autumn New York / Rockaway Beach (Sept - Oct 2025)

What's your professional background? What's your professional background? Fire department Military Police / Law Enforcement Paramedic / EMT Other

Are you still in active duty? Are you still in active duty? Yes, more than 24 hours a week Yes, less than 24 hours a week Yes, currently reported sick from work No, I have been fully disabled. No, I changed profession

Are you being assisted by a Service, Therapy or Emotional Support Dog? Are you being assisted by a Service, Therapy or Emotional Support Dog? Yes a Service Dog Yes a Therapy Dog Yes a Emotional Support Dog Yes, but I will leave the dog at home No