Island Surf and Sport Flagler Beach Surf Camp 2015

Transcription

1 Island Surf and Sport Flagler Beach Surf Camp 2015 Two one week camps available! When: June 15 19, 2015 Where: Si Como No Inn 2480 N. Oceanshore Blvd. Flagler Beach, Fl (386) Price: $599/person if registered & paid in full by May 1, 2015 $649 after May 1 st Age: Price includes transportation, efficiency apartment, meals and all sports activities. Registration: $100 non-refundable deposit is due with each application. All fees due one week before camp start date.

2 Island Surf and Sport Flagler Beach Surf Camp 2015 Registration Form Name: Age: Address: City: State: Zip: Male: Female: School attending: Grade: Phone #: Room with: How did you hear about this camp? T-shirt size: Youth: Med (10-12) Large (14-16) Adult: XSmall Small Medium Large XLarge Level of surfing: Beginner Average Advanced (circle one) Previous IWS Camper? Yes No Registration forms available at the store or online at Please make checks payable to: ISLAND SURF & SPORT Return or mail completed registration & $ deposit to: Island Surf & Sport Attn: Surf Camp 1985 NE 2 nd Street Deerfield Beach, FL Phone (954) Fax (954) *PLEASE SIGN AND NOTORIZE THE ATTACHED LIABILITY RELEASE FORM *PLEASE BE SURE TO FILL OUT ALL THE INFORMATION TO BE ELIGIBLE TO PARTICIPATE

3 Island Water Sports Surf Camp Schedule 6 AM Wake Up 8 AM Surf 8 AM 9 AM Breakfast/Devotions 9 AM 10 AM Surfing lessons 9 AM -12 PM Free surfing 12 PM -1 PM Lunch 1 PM 7 PM Free Surfing, Skateboarding, SUP, Ping-Pong, Slip and Slide 7pm - 8pm Dinner 8 PM 10 PM Music, Giveaways, Bible Study 11 PM Lights Out RULES Cannot leave the property without your counselor No walkmans/cds/mp3s/dvds/gameboys/playstations No Cars No Naps No TV or phone without counselor approval. No members of opposite sex in the rooms. No Fighting SURF CAMP RULES ARE MADE IN ORDER TO ENSURE THAT ALL PARTICIPANTS HAVE A SAFE AND FUN TIME. ALL PARTICIPANTS AGREE TO FOLLOW THE ABOVE RULES. FAILURE TO REPEATEDLY FOLLOW THE RULES WILL RESULT IN THE OFFENDER S PARENTS/GUARDIANS BEING NOTIFIED AND HIS OR HER REMOVAL FROM SURF CAMP. ALSO, SURF CAMP PARTICIPANTS AND THEIR PARENTS/GUARDIANS ACKNOWLEDGE THAT THEY ARE FINANCIALLY RESPONSIBLE FOR ANY PROPERTY DAMAGE THAT THEY MAY DO OR CAUSE TO OCCUR WHILE ATTENDING SURF CAMP. PARENT/GUARDIAN DATE CAMPER

4 ISLAND SURF AND SPORT, INC. MEDICAL INFORMATION, INDEMNIFICATION AND WAIVER As a parent or legal guardian, I hereby give permission for my child to participate in the following activity (the Activity ) organized by Island Surf and Sport, Inc., a Florida corporation. * If the participant is an adult, please complete all that apply. Name of Activity: Island Surf and Sport - Flagler Beach Surf Camp 2015 Participant s Full Name Last First Middle Sex Birthday Age Parent or Guardian Name Home Address Home Phone Business Phone If not available in an emergency, notify: 1. Name Phone Street Address City State Zip Or 2. Name Phone Street Address City State Zip Does this participant have any of the following allergies? Penicillin Date of Last Tetanus Shot: Other Drugs Poison Ivy, Etc. Hay Fever Does this participant have any medical or health problems, and has this participant had any chronic or recurring illness or illnesses, which would have an effect on any participation in this activity? Yes No If yes, describe the problems or illnesses: State the name, address, medical specialty and phone number of this participant s family physician and of any other physician who should be consulted in the event of an emergency or medical problems involving this participant: State the name, address, and phone number of this participant s dentist (and orthodontist if applicable): Is there medical, dental, or hospitalization insurance, which provides benefits for this participant? Yes No Name of Medical Insurance Co. Address Policy/Group Number Member ID # Name of Dental Insurance Co. Address Policy/Group Number Member ID # NOTE: Copies of all insurance Membership ID Cards must be attached to this form. Are there any activities, such as strenuous activities, to be restricted to this participant? Yes No If yes, please describe:

5 Is this participant on any medications? Yes No If yes, please state the medication: If so, will this participant be bringing medications to the Activity? Yes No If yes, please include dispensing instructions if participant is a child: Describe any dietary restrictions (i.e. diabetic, hypoglycemic, food allergies. etc.) Other comments or suggestions from the parent or legal guardian concerning this child or any comments or instructions concerning this participant if an adult NOTE: Island Surf and Sport, Inc. DOES NOT provide medical, dental or hospitalization insurance for any participant attending one of the Programs, Activities or Sporting Events. ALL medical / dental (other than first aid) expenses incurred by the participant will be the sole responsibility of the participant, parent, or legal guardian. Participant, parent or legal guardian will be responsible for providing the appropriate medical, dental, and hospitalization coverage information to the medical provider should the participant require medical / dental services. Participants WILL NOT be allowed to attend Island Surf and Sport, Inc. activities, programs or sporting events without proof of medical, dental or hospitalization coverage. Copies of the participants Membership ID Cards must be attached to this consent form and must contain current up-to-date information. If participant does not have medical, dental, or hospitalization coverage, or cannot provide proof of coverage at time of the Activity, the participant CANNOT attend the Activity until such coverage or proof of coverage is obtained. Parent / Guardian Permission Statement: I further understand that, in the event my child requires medical or dental treatment while engaged in the Activity, reasonable efforts will be made to contact me; however, If I cannot be reached, I hereby consent and give permission to the sponsor or any adult acting with respect to the Activity, as agent for me, to consent to an X- ray exam; injections; anesthesia; medical, dental or surgical diagnosis and treatment; and hospital care and treatment advised and supervised by a physician, surgeon or dentist ( as appropriate ) licensed to practice under the laws of the state where the services are rendered, either as an outpatient or in any hospital. To the best of my knowledge, I have listed above all of my child s medical allergies, medications being taken, medical problems and any other permanent information. My child has permission to participate in all prescribed activities except as noted by me. Parent or Guardian Signature Date ADULT PARTICIPANT STATEMENT (For those over 18 years old): I hereby consent to release the medical information herein to any healthcare provider that is supervising my treatment. I further understand that in the event I require medical or dental treatment while engaged in the Activity and cannot act on my behalf, I hereby consent and give permission to the sponsor acting with respect to the Activity, as agent for me, to consent to any X-ray examination; injections; anesthesia; medical, dental or surgical diagnosis and treatment; and hospital care and treatment advised and supervised by a physician, surgeon, or dentist ( as appropriate) licensed to practice under the laws of the state where the services are rendered, either as an outpatient or in any hospital. To the best of my knowledge, I have listed above all of my medical allergies, medications being taken, medical problems and other pertinent information. Participant Signature Date

6 WAIVER, GENERAL RELEASE AND INDEMNITY AGREEMENT PARTICIPANT / PARENT / GUARDIAN Program / Activity: Island Surf and Sport - Flagler Beach Surf Camp 2015 Name of Participant This Waiver and General Release is for the above mentioned participant with regards to any activity or activities sponsored by Island Surf and Sport, Inc., wherever those activities may take place. In consideration of being given the opportunity to participate in these Activities, I, for myself or my child, my personal representative, assigns, heirs and next of kin: 1. ACKNOWLEDGE, agree and represent that I understand the nature of the activities I am participating in (or that my child is participating in) including the use or operation of any equipment that is necessary to participate in the Activity; and that I / child are qualified to use said equipment. Furthermore, I (or my child) am in good health, and in proper physical condition to participate in all such activities. 2. FULLY UNDERSTAND that: (a) My participation in any or all these activities involves risk and dangers of serious bodily harm or injury, including permanent disability, paralysis and death ( Risks ); (b) These Risks and dangers may be caused by my own actions, or inactions, the actions or inactions of others, including those participating in the Activities, the condition in which the Activities takes place, or the negligence of the Releasees named in paragraph 4 below; (c) There may be other risks and social and economic losses either not known to me or not readily foreseeable at this time; and (d) I FULLY ACCEPT AND ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR LOSSES, COSTS, AND DAMAGES I incur as a result of my or my child s participation in any or all Activities. 3. AGREE AND WARRANT that I will examine and inspect each aspect of the Activities in which I take part and that, if I observe any condition which I consider to be unacceptably hazardous or dangerous, I will notify the proper authority in charge of the Activity and will not take part in the Activity until the condition has been corrected to my satisfaction. 4. I HEREBY RELEASE, discharge, and covenant not to sue Island Surf and Sport, Inc., its directors, agents, officers, sponsors, co-sponsors, affiliates, volunteers and employees, as well as other participating parties to the Activities, and if applicable, owners and lessors of premises, on which the Activities take place, (all of the foregoing considered the Releasees herein) from all liability, claims, demands, losses or damages on my account caused or alleged to be caused in whole or in part by the negligence of the Releasees or otherwise, including negligent rescue operations. In consideration of your accepting me ( the adult participant ) or my child ( the child participant / minor ) for participation in the above program, Activity, or sport, I hereby, for myself, my heirs, executors, and administrators, acknowledge that there are inherent risks associated with any activities such as travel by car, bus or airplane, swimming, surfing, skateboarding, playing or the like, accidents or illness in remote places without immediate access to medical facilities, force of nature, including sun, wind, and rain. I understand that the description of these activities is not complete and other unknown or unanticipated inherent risks may result in injury or death. For the consideration stated above, I further agree that in the event that I ( the adult participant ) or my child ( the child participant / minor ) should make any claims against the Releasees for damages arising out of the above named program, activity, or sport, I will personally INDEMNIFY, DEFEND AND HOLD HARMLESS Island Surf and Sport, Inc. and officers/directors, agents, employees, representatives, sponsors, co-sponsors, affiliates, successors, and assigns against any and all loss and damage occasioned hereby, including attorney s fees. I have read and understand this agreement and have willingly placed my signature below as evidence of my acceptance of all the conditions contained herein. Signatures: Participant Date (If participant is not a minor) Parent (If participant is a minor) Guardian (If participant is a minor) Date Date STATE OF FLORIDA - COUNTY OF BROWARD Before me, a notary public, appeared, [ ] who is personally known to me or [ ] who has produced, upon which I relied as identification, and being known to me to be the person described in and who executed the foregoing instrument, and acknowledged under oath to and before me that he executed said instrument for the purposes expressed therein. WITNESS my hand and official seal on this day of, 20 My Commission Expires: Notary Public, State of Florida Print Name: Commission No.:

7 NORTH BEACH SURF ADVENTURES HOLD HARMLESS AGREEMENT CHILD The undersigned does hereby Release and Hold Harmless North Beach Surf Adventures, LLC, and any of its employees, volunteers and affiliates from any liability that may arise while participating in activities associated with North Beach Surf Adventures, LLC. This Release of Liability and Hold Harmless Agreement is complete and absolute and without reservation. This Release of Liability and Hold Harmless Agreement is to absolve North Beach Surf Adventures, LLC from any liability or responsibility in connection with any injuries or mishaps that may arise or occur to (child s name) during the aforesaid period of time. The undersigned, as the parent/legal guardian of (child s name) has authority to grant this Release of Liability and Hold Harmless Agreement on behalf of (child s name). Dated this day of, 20. Parent/Guardian s Signature Print Name Child s Name STATE OF FLORIDA, COUNTY OF Before me, a notary public, appeared, [ ] who is personally known to me or [ ] who has produced, upon which I relied as identification, and being known to me to be the person described in and who executed the foregoing instrument, and acknowledged under oath to and before me that he executed said instrument for the purposes expressed therein. WITNESS my hand and official seal on this day of, 20. Notary Public, State of Florida Print Name

8 Dear Parents, We re looking forward to another year of Surf Camp, and we re stoked to have your family join ours. We know it ll be the summer of your child s life. However, it s important to know before you go. So, here are few things that we thought you should know: Drop-off will be: At Island Water Sports, June 15 8:30 a.m. Return will be: At Island Water Sports June 19 th - 5:00 p.m. We will be staying at: Si Como No Inn 2480 N. Oceanshore blvd. Flagler Beach, FL (386) In case of emergency you may contact: Cheyne Cottrell (954)

9 Your child will need to bring: Bible Bathing suit (a few pairs) Lycra (rashguard) Sunglasses Leash for Surfboard (if you re bringing a surfboard) Sleepwear - We will be staying in a motel, so bedding is not needed. Beach Towels Toiletries Hat /Visor Wax Skim board (optional) Boogie board (optional) Skateboard (optional) SUNSCREEN, SUNSCREEN AND MORE SUNSCREEN PLEASE MARK YOUR INITIALS ON YOUR PERSONAL ITEMS IN CASE THEY GET LOST!!! What not to bring: No electronics No skateboards No energy drinks What is provided but you can bring your own: Boards (surf, skim, body, stand up paddle) Rash Guard (surfing t-shirt) Water bottle Sunscreen Mask & snorkel Any more questions, call us at the store (954)