RELEASE & HOLD HARMLESS AUTHORIZATION FOR A MINOR For and in consideration of the participation in all Kanoa Beach Camp, and with understanding that said participants will engage in various physical activities on the beach and waters of the Pacific Ocean, we (the undersigned parents or guardians) of the child participant, a minor do forever release, acquit, discharge, and hold harmless Kanoa Beach Camp, County of Los Angeles and its successors, offers, employees, volunteers, servants and agents from any and all actions, claims, damages, cost, loss of services, expenses, and compensation, on account of or in any way growing out of any and all known or unknown personal injuries and property damage which we may not or hereafter have as parents and/or guardians of said minor, and also all claims or rights of action for damages which the said minor has or may hereafter have either before or after he reached his majority, resulting or to result from in connection with participation in and/or arise out of travel to or returning from said program. We the undersigned herby acknowledge to be lawful parents and/or guardians of the above mentioned minor and we therefore acknowledge our qualifications to sign the agreement on behalf of the said minor. Furthermore in accordance with chapter 1524, Section 25.8 of the Civil Code of California, I give authorization to any physician or surgeon, licensed under the provision of Medical Practice Act, for the said participant to receive medical care and/or emergency treatment when necessary. Any expenditure for care is my personal responsibility.

Name of participant____________________________Print

I need transportation from the Pasadena area________ San Fernando Valley_______ (check appropriate location) ***Cost for a round trip ride is $150.00 per week

Date_______________

Signature of Parent / Guardian____________________________

Name_____________________________Print

Date_______________

Age_______ Session Attend. _______________ Please check preference 1/2 Day______

Beach Camp of choice - Venice______ Manhattan______ Malibu_______ (check appropriate camp)

Full Day______

Home Phone (_____)___________________

Work Phone (_____)___________________ School _______________________

Address __________________________________

City _____________________ State _______ Zip ___________

List Two Emergency #

Name __________________________________ Phone (_____)___________________

Name __________________________________ Phone (_____)___________________


All campers will receive a commerative Kanoa Surf Camp T-Shirt. Please select the size (circle): Adult sizes: S M L XL Children sizes: S M L

*Make Checks Payable to: Kanoa Aquatics
For more information call Kip @ (310) 308-7264 Send checks to: Kanoa PO BOX 3582 Redondo Bch., CA 90277-1582

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