Saturday Surf Club

REGISTRATION

Name________________________________________________________________

Current Age_____________________________ Male ______ Female ______

Height _____________________ Weight ____________________ (for wetsuit sizing)

Surfing Experience: Beginning ____________ Intermediate ____________

*All campers must be able to tread water and swim.

Where did you hear about us? Magazine____ Yard Sign____ Flier____

Web Search____ Friend____ Auto Ad____

Saturday Surf Club Desired Dates:

¨September 20^th (Noon – 6 PM)

¨October 18^th (Noon – 6 PM)

¨November 15^th (Noon - 6 PM)

¨December 21^st (Noon – 6 PM)

¨September 6^th (10:00 AM – 4:00 PM)

¨October 4^th (10:00 AM – 4:00 PM)

¨November 1^st (10:00 AM – 4:00 PM)

¨December 6^th (10:00 AM – 4:00 PM)

Cost: $90.00 Includes Transportation, use of Softop Surfboard and Full Wetsuit.

All Drop-off and Pick-up will be in the Rite Aid parking lot at McBean and Decoro behind the Mobil Station.

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 $90.00 payable to:

John Domke

25303 Via Brasa

Valencia, CA 91355

Upon receipt of payment, you will receive an e-mail.

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)

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.

Allergies, medical reactions or unusual physical condition

________________________________ _________________________________

Parent/Guardian Signature Print Name Date