Student’s Name:                                                                                                                                                                                                                                                                                                                 M/F                      birthdate

School____________________________________________________________________________Grade level________

Student cell phone_______________________Student e-mail______________________________________________

How did you hear about us? ________________________________________________________________________

Parent/Guardian Name                                                                                                                                                        

Address                                                                                                                                                                                    

                                           Street                 City                     Zip

Phones: Home#                                                         Cell#                                                                      Work #                                         

Email address:                                                                                                                                                                         

Parent/Guardian Name                                                                                                                                                        

Address                                                                                                                                                                                    

                                           Street                 City                     Zip

Phones: Home#                                                         Cell#                                                                      Work #                                         

Email address:                                                                                                                                                                         

Emergency Information

Alternate emergency contact(s)/ph#__________________________________________________________

I understand and give consent that, in the event of a serious or life-threatening medical emergency that requires immediate treatment, 911 will be called.  I agree that SurferMath is not responsible for any costs incurred if treatment and transportation are necessary.

_____________________________________________________________________________________________

Parent signature                                                                                                           date

Media Release

I consent to have my/our child,                                                                                be photographed for displays on site and/or for public relations for SurferMath.  I understand that there will be no compensation for such displays and public relations pictures.

Signature of parent/legal guardian                                                                               date

Payment enclosed:_______________________________

___________________                                        _________

Administrator Initial                                                   date

Return to: 1804 Soscol Avenue, Suite A, Napa, CA 94559         707.255.7873