Current Age_____________________________ Male ______ Female ______
Height _____________________ Weight ____________________ (for wetsuit sizing)
T-shirt Size _________________
Surfing Experience: Beginning ____________ Intermediate ____________
*All campers must be able to tread water and swim.
Where did you hear about the camp? Magazine____ Yard Sign____ Flier____
Web Search____ Friend____ Auto Ad____
¨[ ] April 6-9 | 11AM- 5PM | $95 Daily
¨[ ] June 22-25 | 8AM- 2PM | $395
¨[ ] June 29 - July 2 | 8AM- 2PM | $395
¨[ ] July 13-16 | 8AM- 2PM | $395
¨[ ] July 20-23 | 2PM- 8PM | $395
¨[ ] July 27-30 | 8AM- 2PM | $395
¨[ ] August 3-6 | 2PM- 8PM | $395
¨[ ] Surf Club (Saturday) _________________________________________________________
Cost: Includes Transportation, use of Softop Surfboard and Full Wetsuit.
Cost: Includes T-Shirt & In-N-Out Thursday. (camp only)
Parent(s) Name(s) _________________________________________________________________
Home Phone_____________________________ Cell Phone(s) ______________________ ______________________
Emergency Name and Contact ______________________________________________________
Insurance Provider ___________________________________ Policy No. ___________________________
Please mail this form and make a non-refundable check for $100.00 payable to:
(For surf club you may bring form and payment the day of the event)
Upon receipt of payment, you will receive an e-mail confirmation securing your child’s placement that you requested.
PARENT’S APPROVAL AND CAMPER WAIVER
Knowing that surfing is an ocean sport that may be potentially dangerous and result in possible injury and/or death, and that some variables may be beyond the control of the said camp and staff members ___________________________________________ has my (our) our permission to be
(Name of Minor)
(Name of Minor)
transported to and from and participate in Surf’s Up Surf Camp instruction and
surfing activities from Santa Clarita Valley to
(Dates of Camp)
(Dates of Camp)
I (we), as parent(s), or guardian(s) of the minor, do hereby, for my (our) _________son/daughter_________, myself, my (our) heir, executors, or administrators, remise, release, and forever discharge John Domke and Surf’s Up Surf Camp employees and agents of each of the foregoing, acting officially otherwise, from any and all claims, demands, actions or causes of action on account of referred.
I hereby certify the minor is my (our) son/daughter and that his/her date of birth is __________________ and I (we) do hereby certify that to the best of my (our) knowledge and belief the said minor is in good health. In case of illness or accident, permission is granted for emergency treatment to be administered. It is further understood that the undersigned will assume full responsibility for any such action, including payment of costs. I (we) hereby advise that the above named minor has had the following allergies, medicine reactions or unusual physical condition which should be made known to a treating physician.
(If none, please write the word “none.”)
* My signature also acknowledges that cell phones, iPods, MP3 Players, digital cameras and other personal items are brought at the campers own risk and will not be the responsibility of Surf’s Up Surf Camp if lost, broken, damaged or stolen.
* My signature additionally acknowledges that any improper behavior including the use of alcohol, drugs, or tobacco is cause for immediate dismissal and no refund will be given.
* My signature allows the use of pictures taken at said surf camp or event to be used on surfsupsurfcamp.com.
Allergies, medical reactions or unusual physical condition
Parent/Guardian Signature Print Name Date