Deerfield Beach Surf Camp 2018 Registration Form

Transcription

1 Deerfield Beach Surf Camp 2018 Registration Form For camp information call or go to Camper s name DOB Parent/Guardian Name Address City State Zip Phone (C) Phone (w) How did you hear about our camp? Name & city of your current school? T-shirt Size (circle one) Youth: S M L XL Adult: S M L XL SPRING SURF CAMP DATES March 26 th - 30 th SUMMER SURF CAMP DATES WEEK 1: June 11 th - 15 th WEEK 2: June 18 th 22 nd WEEK 3: June 25 th 29 th WEEK 4: July 2 nd 6 th (No Camp 7/4; Cost $249) WEEK 5: July 9 th - 13 th WEEK 6: July 16 th 20 th WEEK 7: July 23 rd - 27 th WEEK 8: July 30 th August 3 rd WEEK 9: August 6 th 10 th WEEK 10: August 13 th 17 th

2 AFTERCARE AFTERCARE: 3pm-5pm (Extra $20 per day) Dates Aftercare Needed: COST: 5 day week- $299 per week Daily Option- $99 per day *no discounts on daily registrations *Early Registration discount of $50 available; 10% discount for multi-child/multi week registrations; discounts will not be combined; no discounts on daily registrations Returning Campers: Online registration is now available with a valid user name and password. Visit the Deerfield website at First Time Campers: You may register and pay by fax, mail, online, , or in person at Island Water Sports, 1985 NE 2nd Street, Deerfield Beach, FL Phone: Fax: info@islandcamps.com Camper Drop-off and Pickup : List the names of persons authorized for dropping off and picking up your child at camp: 1. Name Phone 2. Name Phone 3. Name Phone 4. Name Phone I authorize my child to walk home from camp: (please initial) Yes No Emergency Contacts : 1. Name Phone Street Address City State Zip Or 2. Name Phone Street Address City State Zip 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:

3 Describe any dietary restrictions (i.e. diabetic, hypoglycemic, food allergies. etc.) Allergies/Medications: Other comments or suggestions from the parent or legal guardian concerning this child or any comments or instructions concerning this participant Parent or Guardian Name Parent or Guardian Signature Date

4 Island Surf and Sport, Inc. ACTIVITY WAIVER AND RENTAL AGREEMENT NAME: ADDRESS: ADDRESS: DATE: CITY, STATE, ZIP: PHONE NUMBER: NOTICE TO THE MINOR CHILD'S NATURAL GUARDIAN READ THIS FORM COMPLETELY AND CAREFULLY. YOU ARE AGREEING TO LET YOUR MINOR CHILD ENGAGE IN A POTENTIALLY DANGEROUS ACTIVITY. YOU ARE AGREEING THAT, EVEN IF THE RELEASED PARTIES AS DEFINED HEREIN USE REASONABLE CARE IN PROVIDING THIS ACTIVITY, THERE IS A CHANCE YOUR CHILD MAY BE SERIOUSLY INJURED OR KILLED BY PARTICIPATING IN THIS ACTIVITY BECAUSE THERE ARE CERTAIN DANGERS INHERENT IN THE ACTIVITY WHICH CANNOT BE AVOIDED OR ELIMINATED. BY SIGNING THIS FORM YOU ARE GIVING UP YOUR CHILD'S RIGHT AND YOUR RIGHT TO RECOVER FROM RELEASED PARTIES IN A LAWSUIT FOR ANY PERSONAL INJURY, INCLUDING DEATH, TO YOUR CHILD OR ANY PROPERTY DAMAGE THAT RESULTS FROM THE RISKS THAT ARE A NATURAL PART OF THE ACTIVITY. YOU HAVE THE RIGHT TO REFUSE TO SIGN THIS FORM, AND RELEASED PARTIES HAVE THE RIGHT TO REFUSE TO LET YOUR CHILD PARTICIPATE IF YOU DO NOT SIGN THIS FORM. 1. Definitions. The Equipment means the equipment listed above and any of its components. The person who is renting and/or using the above listed Equipment, or participating in any activity sponsored or offered by Released Parties shall be referred to as Participant. The Undersigned means only the Participant when the Participant is age 18 or older OR it means both the Participant and the Participant s parent or legal guardian when the Participant is under the age of 18. Released Parties mean Island Surf and Sport, Inc., God s Grace & Mercy, Inc., and Island Water Sports of Deerfield Beach, Inc., and their respective successors in interest, affiliated organizations and companies, subsidiaries, insurance carriers, agents, employees, representatives, assignees, officers, directors, members, and shareholders. The Activity means renting and/or using the above listed Equipment, or participating in any activity sponsored or offered by Released Parties. 2. Risks of Activity. Participant will be taking part in activities that can be hazardous and involve the risk of physical injury and/or death. The activities are inherently dangerous and Undersigned fully realizes the dangers of participating in the activities. The dangers and risks of the activities include, but are not limited to the condition of the premises and equipment, and the acts, omissions, representations, carelessness, and negligence of the Released Parties. Recognizing the risks and dangers, the Undersigned voluntarily chooses for Participant to participate in the activities and expressly assumes all risks and dangers of the participation in the activity, whether or not described above, known or unknown, inherent, or otherwise. 3. Equipment Use and Damage. The Equipment is rented as is and with no warranties, express or implied. The Undersigned accepts full

5 responsibility for the care of the equipment during the rental period. Undersigned agrees to pay for any damage that occurs to the Equipment and/or the replacement at full retail value of the Equipment regardless of the circumstances under which such damage may occur. Undersigned agrees to pay for the replacement at full retail value of the Equipment for Equipment not returned to Released Parties. Undersigned also agrees to pay for any lost rental income for the period of time the Equipment is out of service due to damage for which Undersigned is responsible. Undersigned agrees to pay for any costs incurred in retrieval of Equipment if abandoned. Undersigned agrees to pay all costs, including reasonable attorney s fees, incurred by Released Parties to collect any sums due or to enforce any terms of this agreement. Undersigned agrees to pay interest of 18% per annum on all sums owed to Released Parties. The Undersigned agrees that Released Parties are authorized and shall have the right to charge the Undersigned s credit card for any sums owed. Improper use of the Equipment, as determined solely by Released Parties, shall result in the immediate confiscation of the Equipment. There shall be no refund of any monies paid in the event of such confiscation and any deposit shall be forfeited. All monies paid for the rental of the Equipment are non-refundable. Undersigned acknowledges that Participant has read and understands the rules for the use of the Equipment 4. Release and Indemnification: In consideration of the Participant being permitted to rent or use the Equipment, or participate in the Activity, the Undersigned (a) unconditionally release, forever discharge, and agree not to sue the Released Parties from and for any claims or causes of action for any liability or loss of any nature, including personal injury, death, and property damage, arising out of or relating to Participant s participation in the Activity, including, but not limited to claims of negligence, breach of warranty, and/or breach of contract the Undersigned may or will have against the Released Parties; and (b) agree to indemnify, defend, and hold harmless the Released Parties from and against any liability or damage of any kind and from any suits, claims or demands, including legal fees and expenses whether or not in litigation, arising out of, or related to, Participant s rental or use of the equipment, or participation in the Activity. IN THE CASE OF A MINOR PARTICIPANT, THE ABOVE WAIVER, RELEASE, AND AGREEMENT NOT TO SUE ONLY APPLIY TO DAMAGES RESULTING FROM INHERENT RISKS OF THE ACTIVITY IN ACCORDANCE WITH FLA STAT Minor Acknowledgment. By signing this Agreement without a parent or legal guardian s signature, Participant, under penalty of fraud, represents that he/she is at least 18 years of age. If signing as the parent or guardian of a minor Participant, signing adults represent that they are a parent or legal guardian of the minor Participant. 6. Miscellaneous. The Undersigned agree: (a) Participant will not engage in any activities prohibited by any applicable laws, statutes, regulations and ordinances; (b) this Agreement shall be governed by the laws of the State of Florida, and the exclusive jurisdiction and venue for any claim shall be located in the state courts located in Broward County, Florida; (c) Undersigned authorizes and gives full consent to Released Parties to copyright and/or publish for public view any and all photographs, digital recordings, videotapes and/or film in which Participant appears. Undersigned agrees that Released Parties may transfer, use, or cause to be used, these digital recordings, photographs, videotapes, or films for any exhibitions, public displays, publications, commercials, art and advertising purposes, television programs, and internet without limitations or reservations; and (d) this agreement shall be binding upon the subrogors, distributors, heirs, next of kin, executors, and personal representatives of the Undersigned. Participant Name: Signature: Age: Date: Parent/Guardian for Participants under 18: Signature: Relation: Date Emergency Contact Name: Emergency Contact - Phone: I HAVE CAREFULLY READ THIS AGREEMENT AND UNDERSTAND ITS CONTENTS. I AM AWARE THAT I AM RELEASING LEGAL RIGHTS THAT OTHERWISE MAY EXIST.

6 MEDIA RELEASE At various times the City of Deerfield Beach and/or Island Surf and Sport, inc. videotapes and photographs events for marketing purposes. By entering yourself or your child in the above mentioned City program, you hereby authorize the City of Deerfield Beach and Island Surf and Sport, inc. to reproduce, copy, exhibit, publish, broadcast or distribute any and all such videotapes, audio tapes or photographs. This includes printed & web photos provided to the parents/guardians at the end of camp. Child s Name: Parent or Guardian Name Parent or Guardian Signature Date Jetski/Wave Runner Release I/we hereby release Island Surf and Sport, Inc. of any and all additional liabilities with regard to any use by my child/children for jet ski/wave runner activities in relation to camp. I/we give permission for my child/children to be pulled by said jet ski/wave runner on a surfboard, boogie board, inner tube, etc. I/we also give permission to have my child/children ride as a passenger with one of our camp instructors on said jet ski/wave runner. This release includes and incorporates everything in the liability release for Island Surf and Sport previously executed. Circle One: Approve Disapprove Child s Name: Parent or Guardian Name Parent or Guardian Signature Date

7 Payment Options Checks : Please make checks payable to: The City of Deerfield Beach Credit Card : If you would like to pay for this activity by credit card, please complete the bottom portion of this page and return it with your registration form. Payment is due in full for all camp sessions Please fill out form completely Charge to (Check appropriate one): Visa MasterCard AmEx Credit Card Number: Exp. Date: Billing Address: City: State: Zip: Amount $ Name on Credit Card: Signature: Card Identification Number: (last 3 digits located on the back of the credit card): Child s Name & Camp Week *NOTE: Discounts cannot be combined. If you are registering before May 1, 2018, you will only receive $50 off each week, regardless of the number of children or weeks you register for. Applications received after May 1, 2018 will receive the 10% multi-child or 10% multi-week discount If you have questions regarding payment amount please call