Background: Developmental impairments persist among adolescents born extremely preterm, and these individuals are at an increased risk for chronic disease later in life. Participating in active and positive leisure activities may act as a buffer against negative outcomes, but involvement in active-physical and skill-based activities is low in youth born preterm. Aims: To explore the child and environmental determinants of leisure participation among adolescents born extremely preterm. Study design: Cross-sectional study. Subjects: Participants were recruited from the hospital’s Neonatal Follow-Up Program and included 128 adolescents born preterm (mean gestational age: 26.5 weeks). Outcome measures: Leisure participation was assessed using the Children’s Assessment of Participation and Enjoyment. Potential determinants were assessed using standardized tests and questionnaires. Selected factors were entered into five separate multivariable regression models. Results: Child and environmental factors contributed between 21% (skill-based) and 52% (active physical) of the adjusted variance for participation intensity. Lower gestational age was associated with greater participation in recreational activities. Male sex, higher maternal education and better motor competence were associated with involvement in active-physical activities. Being older and feeling socially accepted were associated with participation in social activities. Families oriented to hobbies and higher maternal education were associated with participation in skill-based activities. Preference was the strongest determinant of participation in all five leisure activities. Conclusions: Activities should be adapted to individual skill level, include family and peers, foster social acceptance and be driven by the adolescent’s preferences. Although certain factors cannot be modified, they can be used to identify adolescents at risk for low participation.