Name, surname of the participant (child):* ---Mrs.Mr.

Name, surname of the applicant (parents):* ---Mrs.Mr.

Additional people accompanying (names, date of birth):

Street:* No.:* Stair: Apt.:

City.:* ZIP:* Country:*

Tel.No:*
(f.Ex..: 0044 660 123456)

E-Mail:*

Date of Therapy:* ---JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember ---01020304050607080910111213141516171819202122232425262728293031 ---20202021202220232024202520262027202820292030 Number of therapydays: 12345678910111215 days

Location of the therapy:* ---AntalyaGreece

Participants personal data:

Date of birth:* ---JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember ---01020304050607080910111213141516171819202122232425262728293031 ---201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920

Weight:* Size:*

Description of the participant's difficulties or diagnose if available:*

Wheelchair*  Yes No

Headcontrol*  Yes No

Epilepsy*  Yes No

Therapygoals:

Previous and current therapies:

Your travel data if available:

Hotel: Flights (arrival / departure ):

Your prefered therapy time:

You participated in one of our programs before?*  yes no

Do you prefer one of our therapists?

How did you hear about our program?

Upgrades:

 Booking vacation apartment
 Booking free cancellation upgrade for the therapy (EUR 227.-)

Agreements:

 I agree that my dolphin therapy will be photographed and recorded on Video (participants recieve a DVD of their therapy on the last day of therapy)
 I agree that my therapy photos will be published on the dolphinswim AlphaTherapie facebook site

Guidelines and Information download here

I have read the guidelines and accept

Terms of Business download here

I have read the terms of business and accept

Note: After you have completed this online registration DOLPHINSWIM Institute will send you the registration confirmation and invoice with the payment details. The registration is completed with the payment of the initial payment of 20% which must be taken within 1 week. The final payment is due 6 weeks prior to therapy. We will inform you by email on the exact therapy time 3 days upon arrival at the therapy.

Digital signature: Please type the letters presented in the left field below into the field next to it on the right. Consider the use of capital letters: