Isaiah's Autism Family Camp Registration

This application provides you with an exclusive opportunity to enroll your family in Isaiah's Autism Family Camp. Please complete the online application, which requires a $100.00 deposit per person. Once processed, the remaining balance owed will be confirmed via email.

*Please note: Balance due must be paid by check.

Camper Information (Parent)

First Name *

Last Name *

Nickname

Birth Date *

Month

Day

Year

Gender *

Street Address *

Street Address Line 2

City *

State/Province *

Postal Code *

Country *

Email *

Phone Number (Home)

Phone Number (Mobile)

Height *

Weight *

Is this your first time attending Paskowitz Surf Camp?

Yes

Year(s) attended

T-Shirt Size *

Additonal Information

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:

Include surf instruction

Yes

($200.00 for primary parent chaperone or $500.00 for primary parent with surf instruction)

Registration Fee $

Add Parent

Secondary Parent

First Name *

Last Name *

Nickname

Birth Date *

Month

Day

Year

Gender *

Height *

Weight *

T-Shirt Size *

Registration Fee $ ($500.00 for secondary parent)

Camper with Autism

First Name *

Last Name *

Nickname

Birth Date *

Month

Day

Year

Gender *

Height *

Weight *

T-Shirt Size *

Registration Fee $

Number of Additional Campers

Additional campers (siblings or other family members) can be registered at $500.00 per person.

Additional Camper

First Name *

Last Name *

Nickname

Birth Date *

Month

Day

Year

Gender *

Height *

Weight *

T-Shirt Size *

Registration Fee $

Additional Camper

First Name *

Last Name *

Nickname

Birth Date *

Month

Day

Year

Gender *

Height *

Weight *

T-Shirt Size *

Registration Fee $ per person

Additional Camper

First Name *

Last Name *

Nickname

Birth Date *

Month

Day

Year

Gender *

Height *

Weight *

T-Shirt Size *

Registration Fee $

Insurance Information

Insurance Carrier

Policy Number

Physician Information

Prefix

First Name

Last Name

Phone Number

Emergency Contact

First Name

Last Name

Phone Number (Home)

Phone Number (Work)

Ext.

Phone Number (Mobile)

Parents/Guardians - Please accept 'Assumption of risk and release waiver

On behalf of 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 cannot be contacted in an emergency, I hereby grant Paskowitz Surf Camp (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, The City of San Diego, its agents, officers or employees 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, anyone working on their behalf, The City of San Diego, its agents, officers and employees 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.

I accept

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