SEA Participant Enrollment Form

Please fill out the following form so we can best plan for your programs or activities

WHO IS FILLING OUT THIS FORM? *
WHO IS FILLING OUT THIS FORM?
(IF YOU ARE FILLING THIS FORM OUT FOR SOMEONE ELSE)
Best Contact Number *
Best Contact Number
PARTICIPANT INFORMATION *
PARTICIPANT INFORMATION
Does the participant prefer to be called something different than the name listed above? If so, please let us know here.
Date of Birth *
Date of Birth
Please explain
Can the participant swim?
If no, not a problem, it is just good for our staff to know.
We are glad to provide surfboards and wetsuits for participants who need them. Please provide participant height and weight so we can size equipment accordingly.
PARENT/GUARDIAN #1 *
PARENT/GUARDIAN #1
If participant is under 18 years of age
Phone *
Phone
Primary contact number
Phone 2
Phone 2
Phone 3
Phone 3
Address *
Address
PARENT/GUARDIAN #2
PARENT/GUARDIAN #2
Phone 1
Phone 1
Phone 2
Phone 2
Phone 3
Phone 3
Address 1
Address 1
EMERGENCY CONTACT #1 *
EMERGENCY CONTACT #1
(If different than Parents/Guardians)
Phone 1 *
Phone 1
Primary contact number
Phone 2
Phone 2
Phone 3
Phone 3
EMERGENCY CONTACT #2
EMERGENCY CONTACT #2
Phone 1 *
Phone 1
Phone 2
Phone 2
Phone 3
Phone 3
Please list the names of people who are allowed to pick up or check out the participant (other than those listed above as parents/guardians or emergency contacts).
Physician Address *
Physician Address
Please list any medical concerns and/or problems, including any requiring maintenance medication (i.e. Diabetic, Asthma, Seizures)
Please list any medical conditions that our staff should be aware of.
Is the participant presently being treated for an injury or sickness, or taking any form of medication for any reason?
Is the participant allergic to any type of food or medication?
Does the participant require a special diet?
CONSENT FOR MEDICAL SERVICES *
I understand that I will be notified in the case of a medical emergency involving my child. In the event that I cannot be reached and other parents/guardians and emergency contacts cannot be reached, I authorize the calling of a doctor and/or the providing of necessary medical services in the event myself or my child is injured or becomes ill.
FINANCIAL RESPONSIBILITY FOR MEDICAL EXPENSES *
I understand that the Surf Education Academy and it’s officers, owners, volunteers and staff will not be responsible for any medical expenses incurred, but that such expenses will be my responsibility as participant or parent/guardian.
PHOTO, VIDEO & MEDIA RELEASE *
I hereby give permission for the participant to be photographed and/or filmed during the program, camp, course, clinic or activity. I understand the photos may be used for training purposes, shared as promotional materials (including flyers, brochures, in print, on the internet, etc.), or used in curriculum. I understand that although the participant's photo or video may be used for promotion, his or her identity will not be disclosed without permission; I do not expect compensation and that all photos and video are the property of Surf Education Academy. If you do not want imagery of the participant used for promotional reasons, please let us know in writing and we will not feature images with named participants as the focal point; however, participants may appear in the background of other imagery.
TRANSPORATION RELEASE *
I hereby give permission for the transportation of the participant to and from Surf Education Academy activities by Surf Education Academy.
PERSONAL PROPERTY RELEASE *
I agree the Surf Education Academy is not responsible for lost or damaged personal property during, prior or after activities.
SCHEDULING RELEASE *
All scheduled events are subject to change. I agree that Surf Education Academy is not responsible for any funds lost due to changes in scheduling, reservations, accommodations, transportation, etc.
ACCURATE & COMPLETE INFORMATION
I certify that the information provided is both accurate and complete, with all vital information accounted for.