• missalette
• rosary
• sunscreen

• toiletries
• 2 towels
• clothing for 7 days

• sandals
• tennis shoes
• vaseline

• swimming suit (trunks for boys, or one-piece suit for girls)
• photocopy of front and back of medical insurance card
• spending money (optional)
• disposable camera (optional)

• radios, CD/MP3/DVD players
• video games
• valuables (digital cameras, expensive jewelry, etc)

• Attached in the amount of $500 non-refundable deposit, required for reservation.

• I will pay the $999 balance on or before the first day of my child's session.

CYWN Affiliation #: CQC026 (Boys)

Name: California Surf Camp for Boys

Location: San Juan Capistrano, CA

Dates: July 13 - 19, 2008

NATURE AND DURATION OF ACTIVITIES: 5 days of surfing, sightseeing, swimming, sports, spiritual and social activities

ACTIVITY SUPERVISORS: Authorized camp supervisors

TRANSPORTATION: Provided by volunteer dads

REQUIREMENTS: The child named above is in good health and has no physical or medical limitations that would cause the activities as described above to be detrimental or dangerous to the child. Parents/guardians should specify allergies and medical problems in section 9 below.

CONSENT: I/We hereby consent to the above-named child's participation in the activities described above, and specifically request that he or she be allowed to participate in those activities. I/We warrant that I/We have full authority to legally consent to his or her participation in the activities described on this form, and all provisions contained herein.

AUTHORIZATION: I/We hereby authorize ConQuest NA, Inc./Challenge NA, Inc. to use the image and likeness of my child in photograph or video form whether taken by or commissioned by ConQuest NA, Inc./Challenge NA, Inc. in its promotional materials and for its promotional purposes associated with its nonprofit activities. This authorization shall extend to use of my child's image and likeness on the website of ConQuest NA, Inc./Challenge NA, Inc., or its successor in operation or affiliated organization(s) upon written consent of ConQuest NA, Inc./Challenge NA, Inc. I/We understand that this authorization shall survive the end of my child's participation in the activities referenced on this form.

INSURANCE: I/We understand that ConQuest NA, Inc./Challenge NA, Inc. does not carry any insurance relative to the activities or for any injury that may occur to the above-named child. I/We represent that the child is (a) covered by insurance through my own insurance carrier; or (b) that I/We am personally financially responsible for any and all medical costs incurred as a result of the child's injury.

EMERGENCIES: If the above-named child requires any emergency medical procedures or treatments during the activities, I/We consent to the activity supervisor(s) taking, arranging for or consenting to such procedures or treatments in the discretion of the activity supervisor(s). For purposes of such procedures and treatments, my child's blood type is and my child has the following allergies or other medical problems (if any): .

RELEASE AND INDEMNIFICATION: I/We release and waive, and further agree to indemnify, hold harmless or reimburse ConQuest NA, Inc./Challenge NA, Inc., the individual members, agents, directors, officers, employees, volunteers and representatives thereof, as well as activity supervisors, from and against, any claim which I, any other parent or guardian, any sibling, the above-named child, or any other person, firm or corporation may have or claim to have, known or unknown, directly or indirectly, for any losses (including attorneys' fees incurred by ConQuest NA, Inc./Challenge NA, Inc. or any of its individual employees, agents, volunteers, etc. in enforcing this indemnity provision without limitation in time or amount, damages or injuries arising out of, during, or in connection with the child's participation in the activities, the travel to and there from, and the rendering of emergency medical procedures or treatment, if any. I/We understand that this release and indemnification shall survive the end of my child's participation in the activities referenced on this form.

If, in the event of a medical or other emergency, I/We am unable to be reached by telephone at my home or work telephone numbers listed below, I/We authorize the activity supervisor(s) to attempt to contact me/us through the emergency contacts listed below.

I/We have read and understand the above.

DATE: