JG Application 2012
How did you hear about our program?
Please Select
Family or Friends
Ad in Newspaper
Internet Search
Flyer or Tidebook
Hobie or other surfshops
Returning Customer
Other
If referred by Family or Friend, Please enter his/her name :
PARENT/GUARDIAN INFORMATION
First Name:
*
Last Name:
*
Address:
*
City:
*
State:
*
Zip:
*
Phone:
*
E-Mail:
*
CHILD'S INFORMATION
What school does your child attend?
*
Was your child in our program in
2011
?
*
No
Yes
First Name:
*
Last Name:
*
Birth Date:
*
(Month) (Day) (Year)
1
2
3
4
5
6
7
8
9
10
11
12
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
HEALTH INFORMATION
Does your child have any health problems or medical history that affects their ability to participate in strenuous activity?
Yes
No
If "YES" (Please Explain Briefly):
SESSION(s)
[ One Session $ 445 ] [ Two Sessions $ 855 ] [ Three Sessions $ 1,265 ]
UNIFORM INCLUDED IN PRICE: Board Shorts, T-Shirt, Hat, Rashguard
Please select from the following:
Session 1: (June 25 - July 13, 2012) (M-F: 9am-3pm)
(NO JUIOR GUARDS JULY 4th)
Session 2: (July 16 - August 3, 2012) (M-F: 9am-3pm)
Session 3: (August 6 - August 24, 2012) (M-F: 9am-3pm)
*CANCELLATION FEES DO APPLY *
EMERGENCY INFORMATION
In Case of EMERGENCY Contact
Name:
Relationship:
Address:
Phone:
Questions & Comments: