Surf Camp Registration Form | Peninsula Outdoors

Participants Full Name

Parents Name

Parents Email

Parents Phone

Other/ any dietary details

Allergic - please provide details

Anaphylactic - please provide details - Please send ASCIA Plan

Medical Conditions

None

Heart Condition

Breathing Condition

Asthmatic

Other - please list

Swimming Ability

Non Swimmer - Cannot swim and partake in water activities

Beginner - Can swim with assistance of flotation aid

Strong Swimmer - Can comfortably swim 50-100m

I agree to the terms and conditions outlined in the RISK WARNING, WAIVER AND EXCLUSION OF LEGAL LIABILITY FOR PARTICIPANTS - view here

Name of Participant

Name and address of parent, guardian or person performing parental responsibilities for Participant

Date of Birth and Age of Participant

Day

Month

Year

Age

Emergency Contact Name (must be over 18 years of age) and Relationship to Participant

Emergency Contact Phone Number

Signature

Signature field is empty.

Date of Signature

Day

Month

Year