Tel: (805) 218 1484
Fax: (805) 985 1220
email:

Ventura Surf School
607 W. Channel Islands Blvd.
Port Hueneme, CA
93041

www.venturasurfschool.com

First Name:

Last Name:

Address:

City:

State & Zip:

Parent/Guardian:

Child's DOB

Home Phone:

Work Phone:

Mobile Phone:

E-mail address

Emergency Contact:

Doctor:

Doctor Phone:

Health Insurance Policy #:

Allergy/Health/
Medication Requirements:

Swimming Ability
(Circle One)

Beginner

Intermediate

Advanced

Surfing Ability
(Circle One)

Beginner

Intermediate

Advanced

T-Shirt Size
(Adult sizes) (Circle one)

Small

Medium

Large

X-Large

Do you have?
(Circle)

Surfboard Wetsuit

Which school do you attend?

How did you hear about
Ventura Surf School?

Page 1 of 3

Which session(s) would you like to attend?
(Circle All Sessions Desired)

Session 1: June 16th - 20th

Session 2: June 23rd-27th

Session 7: July 28th - Aug 1st

Session 3: June 30th - July 4th

Session 8: Aug 4 - 8th

Session 4: July 7th- 11th

Session 9: Aug 11 - 15th

Session 5: July 14th- 18

Session 10: Aug 18-22

HOURS: 9am to 4pm Monday - Friday.
Extended hours are available please ask for details.
Meeting place is at Marina Park. Call for directions if needed.

PRICE: $350 per week.
For two or more weeks take a 10% discount.
50% deposit required to hold a space. Balance due Friday before class starting date.
A full refund will be made if cancellation is received at least 72 hours prior to start of reserved class.
Send check or credit card details and completed application to the above address.

Credit Card Number

Credit Card Expiration Date

Name on Credit Card

We also offer birthday parties and private lessons for all ages.

We, the undersigned, hereby acknowledge that the activity of "Surfing" to be performed by my person is a sporting activity which by its own nature is a hazardous physical activity on the beaches and waters of the Pacific Ocean involving risk of serious injury and/or death, and I am voluntarily participating in these activities with knowledge of the dangers involved and I hereby agree to accept any and all risks of injury or death.

For and in consideration of the participation in the Ventura Surf School, we the undersigned, the father and mother and/or guardian of the said participant, a minor, do hereby for ourselves, executors, and administrators, agree to forever waive, release, acquit, discharge, and hold harmless, the Ventura Surf School, County of Ventura, City of Ventura, County of Santa Barbara, City of Santa Barbara, City of Carpinteria, State of California, and its successors, principals, officers, employees, volunteers, servants, and agents from any and all liability, rights, damages, claims, actions, costs, loss of service, expense and compensation, on account of or in any way arising from any and all known or unknown personal injuries and property damage, which we may have before or after reaching the age of majority, and resulting from the aforementioned surfing activity and the collateral activities of the Ventura Surf School pertaining thereto.

We the undersigned hereby acknowledge to be the lawful parents and/or guardian of the above mentioned minor and we therefore, acknowledge our qualifications to sign the subject agreement on behalf of the said minor.

Date:

Print Name:

Participant Signature:

Date:

Print Name:

Parent/Guardian Signature:

In the event of a medical emergency, I give my consent for medical treatment that may be necessary.

Date:

Print Name:

Parent/Guardian Signature: