1. Call or email L.B.I. Surfing Lessons to confirm openings: 609.494.SURF or 7873

lbisurfing@hotmail.com

2. Fill out, and sign this form.

3. Mail this form along with your deposit to:

162-F Long Beach Blvd.

Loveladies, NJ 08008

ENROLLMENT INFO:

First Name: ______________________________________________ Male ______ Female _____

Last Name: ______________________________________________

Age _____________ Date Attending: __________________________

PARENT OR GUARDIAN INFO:

Name: _____________________________________ Relationship _______________________

Address: ____________________________________ City ______________________________

State: _____________________ Zip: ___________________

Home Phone: _________________________ Day Phone: ______________________________

E-Mail: _______________________________________________________________________

EMERGENCY CONTACT INFO:

Name: ____________________________ Relationship: _______________________________

Phone #: ________________________

MEDICAL INFO:

Allergies: _____________________________________________________________________

Medical Problems: ______________________________________________________________

Medication: ___________________________________________________________________

Notes: _______________________________________________________________________