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| Name:
Insurance Company:
Policy #:
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| IN CASE OF EMERGENCY, PERSONS
WHO MAY BE CONTACTED AND TO WHOM INDIVIDUAL MAY BE RELEASED:
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Mother/Guardian:
Phone:
Father/Guardian:
Phone:
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| IF THE ABOVE PERSONS CANNOT BE REACHED,
WE CAN CONTACT AND OR RELEASE THE INDIVIDUAL TO: |
Relative/Friend:
Phone:
Relative/Friend:
Phone:
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| SHOULD A SERIOUS INJURY OR ACCIDENT
OCCUR AND WE ARE UNABLE TO CONTACT THE PARENTS AND/OR FAMILY PHYSICIAN,
PERMISSION IS HEREBY GRANTED FOR MEDICAL CARE TO BE GIVEN AS REQUIRED.
THE UNDERSIGNED PARENT OR GUARDIAN IS RESPONSIBLE FOR ANY FEE INVOLVED. |
| Parent/Guardian: _________________________
Date:
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| DOES THE PARTICIPANT HAVE ANY MEDICAL
CONDITIONS OR RESTRICTIONS? THIS WOULD INCLUDE ALLERGIES AND MEDICATIONS
TAKEN ON A DAILY BASIS. |
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| By signing this waiver,
I, intending to be legally bound, acknowledge the possibility of my child/
dependent/ myself being injured while attending the ENDLESS SUMMER SURF
CAMP does exist. Surfing is a dangerous sport, and such hazards as hidden
rocks, rip tides, sting rays, other marine life, and other dangers that
come with the sport of surfing do exist. I/we fully recognize and understand
the nature and existence of these inherent risks. In the event of any
injury to my child/dependant/myself, (including my heirs and assigns),
I hereby waive, hold harmless, and forever discharge from any liability
damages or claims for damages for personal injury, including accidental
death, as well as for claims of property damage against the ENDLESS SUMMER
SURF CAMP,Progressive Surf Camps, Inc., Jason C. Senn, the camp's director
and any officials, employees, or sponsors connected with this camp, and
the US government, the State of California, and their members or agents.
I also understand that any disruptive or damaging behavior on my part
or on the part of my child will be due cause for dismissal from this camp,
with no refund. |
Signature: _________________________ Date
Parent/Guardian: _________________________ Date:
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