No : Office use only: Course selected: C1 Level 1
C2
Method of Payment: Rp
C3 C4 Level 2 US$
C5 C6 Level 3 C.C.
C7 C8 Private
Voucher
C9 C10 Private Kid
F.O.C.
Reef
Other__________________
Amount Paid:_________________ Promotion:________________ Agent’s Name:_____________________________ Comment: _________________________________________________________________________________________
Name ____________________________________________________________ Date of Birth / Age __________________ (First name) (Last name) Email Address __________________________________________________________________________________________ Address _______________________________________________________________ Country ________________________ Hotel name and room no. ________________________________________________________________________________ How did you hear about Rip Curl School of Surf? ______________________________________________________________ Please sent me the Rip Curl
Newsletter
Swell Forecast
In consideration of the acceptance to participate in lessons at the Rip Curl School of Surf, I have read, understood, approved and agree to the following terms and conditions:If a following conditions applies to you please tick YES –
NO
YES
ASTMA EPILEPSY PREGNANCY HEART CONDITIONS A PREVIOUS INJURY THAT MAY REOCCUR (A) I accept that water sports activities carry some degree of risk both to the person and property. Knowing the risk involved, I still wish to register for a lesson with the Rip Curl School of Surf and so expressly agree to assume the risk of injury or damage while participating in these activities. (B) I release, waive and hold harmless Rip Curl School of Surf, its officers, agents and/or employees from all claims, losses, damages or expenses during or in conjunction with my participation in Rip Curl School of Surf, including any claims for damage caused by the negligence of Rip Curl School of Surf, its officers, agents and/or employees, together with any cost including legal fees that may be incurred as a result of any such claims, losses, damages or expenses whether valid or not. (C) I also indemnify the Rip Curl School of Surf, its officers, agents and/or its employees against all claims losses damages, expenses or claim that any one or more of their executors, administrators, heirs, next of kin, successors or assignees may have and against any costs including legal fees that may be incurred as a result of any such claims, losses damages or expenses whether valid or not. (D) If I am not a resident of Indonesia, I declare that I will not avoid Conditions (B) or (C) by commencing any legal action in another country. (E) I declare and confirm that I am physically fit and have no conditions or injury that could be affected by this activity (as previously stated). (F) I hereby consent to receive medical treatment which may be deemed necessary by Rip Curl School of Surf in the case of injury, accident or illness during the course of undertaking the water sport activity and also agree to indemnify Rip Curl School of Surf in the respect of such medical treatment. (G) I accept responsibility for the equipment, including helmet, wetsuit, booties, shorts and rash shirt in which the Rip Curl School of Surf has allocated to my name. I hereby agree to pay for all repairs or replacement in such case of negligence or loss. (H) I agree to waiver all responsibility and medical insurance coverage from the Rip Curl School of Surf when refusing to wear the supplied helmet. (I) I agree that any films, sound or other recording of my water sport activity will not be used in any promotion or advertising without the prior consent of Rip Curl School of Surf. I also agree the company itself may use such recordings as it deems fit without any prior consent. (J) I accept that all refunds for course not completed will be given in the form of vouchers. (No cash refunds). (K) I agree that this agreement shall be governed in all respect by and in accordance with the laws of Indonesia. Full Name
_______________________________________
Signature _______________________________________
This Day
_______________________________________
(Parent’s or Guardian’s Signature if under 18) In the presence of ________________________________ (Receptionist)