Child’s Name________________________________________________________________


Current Age_____________________________             Male ______             Female ______


Height _____________________             Weight ____________________ (for wetsuit sizing)            


T-shirt Size _________________

                        CAMPS ONLY


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____


Desired Camp Dates 2023:


¨April 4-6 | 12PM - 3PM | $125


¨June 26 -29 | 9AM - 1PM | $450


¨July 10-13 | 9AM - 1PM | $450


¨July 17-20 | 3PM - 7PM | $450

¨July 24-27 | 9AM - 1PM | $450

¨July 31-Aug 3 | 3PM - 7PM | $450


¨ Aug 7-10 | 9am-1pm | $450

¨ Surf Club (Saturday)      _________________________________________________________



Cost:  Includes 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) ______________________  ______________________


E-mail _________________________________________


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)


John Domke

23930 Avenida Crescenta

Valencia, CA    91355



Upon receipt of payment, you will receive an e-mail confirmation securing your child’s placement that you requested.




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)




transported to and from and participate in Surf’s Up Surf Camp instruction and surfing activities from Santa Clarita Valley to Ventura, California and back to Santa Clarita Valley _________________________________.

(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  





Allergies, medical reactions or unusual physical condition


__________________________________           ___________________________________

Parent/Guardian Signature                              Print Name                                Date