PASKOWITZ SURF CAMP

SURF CAMPER APPLICATION SAN DIEGO - 2012

Please complete this application to enroll your child or yourself in Paskowitz Surf Camp for the summer of 2012. Applications are accepted on a first come, first-serve basis. There is limited enrollment in each week of camp. Please complete application, and return with a $300.00 (per person) deposit. fill out and fax back to Danielle

Last Name _________________________________________________   First Name _____________________________________________________________

Height ______________      Weight _______________      Birthday _______-_______-______          Sex:        MALE         FEMALE

CELL________________________________________/____________________________________ EMAIL_________________________________________

Address__________________________________________________________     Home Phone____________________________________________________

City__________________________________ State__________ Zip_________      Other Phone ____________________________________________________

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           PICK DATES _______________________________________1 St. Choice __________________________________________________________ 2nd Choice     

Circle T-Shirt size:        (Child’s Sizes)     SM    MED    LG    XL        (Adult Sizes)    SM    MED    LG    XL

Insurance Carrier ________________________________   Insurance Policy Numbers ____________________________________________________________

Family Physician____________________________________        Phone ______________________________________________________________________

Please note ANY special information that we should be aware of, i.e. medical issues, required medication, allergies, and special needs

with regards to diet, special social or physical  needs:

__________________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________

PARENT FILL OUT INFORMATION FOR YOUR CHILD:

Briefly describe you and or your child’s personality—is he shy, outgoing? Any special social concerns? :

__________________________________________________________________________________________________________________________________

Are there any special areas at camp that you would like to place special emphasis on?

__________________________________________________________________________________________________________________________________

Mother’s First Name_____________________      Last Name_________________________       E mail_______________________________________________

Mother’s Phone    Work_____________________________      Home____________________     Cell________________________________________________

Father’s First Name_____________________      Last Name_________________________       E mail_______________________________________________

Father’s Phone    Work_____________________________      Home____________________     Cell________________________________________________

Address__________________________________________________________     Home Phone____________________________________________________

City__________________________________________________________ State__________ Zip_________      Other Phone ____________________________

Father’s occupation______________________________________       Mother’s Occupation_______________________________________________________

Grade next Fall ________    School _____________________   Is this your first year at PSC?_____   If not, when? _____________________________________

Child resides with:       MOTHER     FATHER      BOTH       OTHER (specify)__________________________________________________________________

Who should receive correspondence at the address above?    MOTHER      FATHER               BOTH

How did you learn about the Paskowitz Surf Camp? (Friend, magazine, internet, etc.)

__________________________________________________________________________________________________________

Will you be bringing a wetsuit (full suit 3x2 recommended)?   YES    NO        Will you be bringing your own surfboard?      YES    NO

Number of Years Surfing? _________________     Describe Your Swimming Ability_____________________________________________________________

Emergency Contact, in the event both parents are unavailable:

Name___________________________________________        Relationship____________________________________________________________________

On behalf of myself and or my child, I accept and assume any and all risks associated with his/her attendance and participation in the camp and its activities. I understand that my child should not attend the camp if he/she is not healthy. I understand that my child must abide by camp policies and the instructions of the camp staff. I agree that should my child be dismissed from camp no part of my tuition will be refunded. I understand that no reduction in the tuition will be made for late arrival, early departure, vacations, illness or injury. In the event that I can not be contacted in an emergency, I hereby grant PSC. (PSC) permission to give immediate treatment and/or take my child to a hospital emergency room. Permission is hereby granted for photographs and/or videos to be taken of my child at camp and PSC has the right to utilize these in our brochures, videos, slide shows, web site, and other camp materials. Permission is also granted for my child (if enrolled in Surf Camp) to attend all scheduled field trips. Knowing these facts and in consideration for your accepting my child's application, I, for myself, my child attending the camp, and anyone else who might claim on my or my child's behalf ("I"), hereby agree that neither PSC are responsible for accidents, injuries, and/or medical or dental expenses arising from my child's participation in the camp and, accordingly, I covenant not to sue, and waive, release, and discharge PSC, and anyone working on their behalf from any and all claims of liability or expenses of any kind or nature whatsoever arising out of or relating to my child's participation in the camp. I have carefully read all of the information in this application form and agree to all conditions.

HOW TO ENROLL IN CAMP

Please complete both sides of this New Enrollment Application form, sign the form, and mail it with a $300 per person deposit to the mailing address below. Applications will also be accepted by fax (949) 728-1200. The balance of the tuition is due FOUR weeks prior to camp. VISA/ MC/ AMEX are accepted for the deposit, but the balance due must be paid by check.

FAMILY OR GROUP DISCOUNTS

A 5% family discount is given to all families enrolling two or more children. This discount applies only to children enrolled after an initial child is enrolled. Discount applies only to children in your immediate family. A 5% group discount is also available for each member of a group of four or more campers.  In order to receive this discount, all applications must be sent together in the same envelope. Please note: Only one discount applies per camper (i.e. family or group).

CANCELLATIONS AND CHANGES

If you need to cancel your child’s enrollment in camp, you must notify us in writing by April 1, 2012 in order to receive a refund. Cancellations on or prior to this date are subject to a $50 processing fee per child. No refunds will be given out after April 1, 2011, regardless of your registration date. Changes in the enrolled weeks are based upon availability. Full credit may be applied.

CHECKS PAYABLE TO: Paskowitz Surf Camp    PLEASE SEND FORM TO:  Paskowitz Surf Camp, P.O. Box 522, San Clemente, CA 92674

If you have questions or scheduling problems, call Danielle Paskowitz at (949) 728-1000.  She can also be reach on her cell: (949) 290-9420

To speak to Camp Director Izzy Paskowitz, call (949) 463-WAVE.  OUR FAX (949) 728-1200.

WE CAN PICK UP YOU OR GROUPS AT NO ADDITIONAL COST FROM – SAN DIEGO/ LINDBERG FIELD OR SAN DIEGO TRAIN STATION.

*NOTE: PLEASE ALSO ATTACH SCHOOL PHOTO OF YOU'RE CHILD

*NOTE: WETSUITS ARE NOT A SHARED ITEM ACCORDING TO OUR POLICY. PLEASE PROVIDE YOU AND OR YOUR CHILDREN WITH A BASIC FULL SUIT 3MM X 2MM.

FOOD ALLERGIES:________________________________________________________________________________________________________________

FOOD LIKES OR DISLIKES:_______________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________

SESSION________________________________________________ CAMP GROUP____________________________________________________________

CAMPER ID#____________________________________________ CAMPER NOTE ___________________________________________________________

ARRIVAL ___________train/plane/car DATE_______________________________ TIME________________________________________________________

CARRIER___________________________________________________________ Flight/ Train #__________________________________________________