Language
English (US)
Spanish (Latin America)
April 11th - Ocean Education and Skateboarding Clinics
Parent / Guardian Information
(All correspondence will be sent to this person)
Name
*
First Name
Last Name
Email
*
example@example.com
Cell Phone
*
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Child's Information
Personal
Name
*
First Name
Last Name
Birth Date
-
Month
-
Day
Year
Date
Age
Please Select
5
6
7
8
9
10
11
12
School Child Attends
Preferred language
Spanish
English
Either
Child's Health Information
List any allergies
Significant Medical History (surgery, injuries, serious illness, etc.)
List any Medical Problems (asthma, seizures, headaches, etc.)
List any medication taken regularly (please note if any medication must be administered during camp)
Emergency Contact and Authorized Pick Up
Emergency Contact (Additional to parent registering child)
Authorized Pick Up Persons (Additional to parent registering child)
Authorized Pick Up Persons (Additional to parent registering child)
Waivers &Terms
Please wear closed toed shoes!
Date
-
Month
-
Day
Year
Date
Signature
Submit
Submit
Should be Empty: