If your child has any medical problems or needs notification MUST be in
advance to participate in the camp. Power of attorney for one week will be required, if I am required to take your child a
medical facility if need be.
Student Name:___________________________________________________________
Date: ______________________ E-Mail: __________________________________
Mailing Address:
Street __________________________________________________
City: __________________ State: __________
Zip: ___________
Age: ____ Male: ____ Female: ____
Insurance Information____________________________________________________
(provide copy of insurance card along with power of attorney)
Address ____________________________________________________
Phone Number ________________________________________________
Policy Number ________________________________________________
Emergency Contact: Name: _____________________________________
Phone #: ____________________________________________________
DOB___________________Social Security Number___________________
Your
Home Phone_______________________________
Cell Phone ________________________________
Work Phone_______________________________
All students, and guardians of participating students, prior to enrollment and participation with
Sharkey's Surf Camp affiliated with Ron Jon Surf School SM*,
(referred to herein and after in this document as RJSS)
MUST first read, then
complete the following Indemnity and Acknowledgement Agreement.
I,
_________________________________________agree to assume all risks
incidental to participation in (Student Name)
_____________________________
agree that I have given legal consent to allow Donna "Sharkey" Avery to supervise
and chaperon my child while attending surf camp at Ron Jon's Surf School Camp and while under Donna "Sharkey"
Avery's care while not at the RJSS camp for the week of_______~________and will not hold Miss Avery ,Craig Carroll or
Ron Jon's liable or responsible for any inappropriate behavior or incident on the part of my child_______________________________________while
being involved with surfing, water sports, and related activities associated with Sharkey and the RJSS. I hereby grant
permission for myself /giving permission to Donna "Sharkey" Avery under the guardianship for the term of one week,for
my child to attend the RJSS.
I hereby release Donna "Sharkey" Avery
and RJSS from any and all liabilities, claims, actions, damages, costs, and/or expenses, arising from or in anyway connected
with my participation in all surf school and their related activities conducted by RJSS and while under the supervision of
Donna "Sharkey"Avery.
I hereby agree that RJSS, employees, and
affiliates, are not responsible or liable
for any injuries or damage resulting from any participation in of the supervised
activities outside camp and while in or out of camp at any RJSS activities.
I understand and acknowledge
that surfing and other water sports and related activities are inherently dangerous activities.
I
acknowledge and assume any and all risk associated with the presence of any and all sea life that may be in the water or on
the beach. I assume the entire responsibility of the performance of the activities associated with this agreement.
I further expressly agree to indemnify and hold harmless Donna "Sharkey" Avery,
RJSS, Cocoa Beach Surfing
School, LLC., and Ron Jon Licensing, Inc.,
their directors, officers, employees, and affiliate companies for any and
all claims for injury to persons or damage to property or any other damages or losses by anyone,
all of the foregoing
to include all expenses and charges including attorneys fees, which may arise out of, or in connection with, the activities
associated with this agreement, or which are alleged to have arisen out of activity associated with this agreement. Right
To Photograph: By signing this agreement I hereby give my consent and approval to the RJSS, that they shall have the rights,
without obtaining my further approval, to photograph, take motion pictures of, televise, or reproduce in any manner or through
any media, images of myself, my child, and my legal guardians. RJSS shall have the right to, display, use, sell or license
any such pictures or other reproductions for any purposes commercial or otherwise without monetary compensation to myself,
my child or my legal guardian.
Yes ______ No _______ (Please Check One )
I hereby
authorize any RJSS personnel to conduct any minor Medical First Aid that may
be required for my child or myself.
Yes ______ No _______ (Please Check One )
I hereby authorize any Physician
or Nurses selected by RJSS personnel to order and conduct medical or surgical procedures deemed necessary for myself or my
child in an emergency situation. I understand that I will be responsible for all Hospital, Laboratory, and Doctor Fees.
Yes ______ No _______ (Please Check One )
I verify that I am in good health and am fully capable of
participating in any and all strenuous activities associated with any RJSS activities. I fully understand that each participant
must be a competent swimmer and acknowledge that I am a competent swimmer.
Students signature: __________________________________________
Date: __________
I, ____________________________________
as the parent or legal
guardian of
__________________________
(Students Name)
__________________________
(Guardians Name)
I ___________________________________the Parent/Guardian
of_______________________give permission for Donna "Sharkey" Avery to chaperon and supervise and involve the
participation of my child's activities.I also give my permission for my child or Ward to participate in RJSS activities.
I do understand and acknowledge the above stated risks associated with my child or Wards participation in surfing
related activities with the RJSS & Sharkey's Surfing Adventure Camp.
Parent
or Legal Signature
Guardian:__________________________________________Date:___________
Pint name also please clearly___________________________________________
