Adaptive Surf Lesson Booking

*
First Name Surname
Email*
Address*
Street Address Address Line 2 City County / State / Region ZIP / Postal Code
Contact Number*
Requested Private Lesson Date
DD slash MM slash YYYY
Requested Private Lesson Time
: Hours
Minutes
AM/PM
Disability & cause:*
Date of onset/injury*
MM slash DD slash YYYY
Any medication and/or physical medical support i.e. catheter, wheelchair etc.*
On a scale of 1-5, how comfortable are you in the water?*
Any other important info i.e. any pain, if so when?*
Do you want to receive our monthly newsletter with specials and upcoming events?
- Yes
- No
I accept the terms and conditions
- Yes
- No
View the Terms and Conditions
Comments
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Terms and Conditions

In consideration of your acceptance of my application, I hereby indemnify, absolve, exempt and release Muizenberg Surf Shop, Roxy’s, Surf Emporium, Roxy Surf School, Roxy Learn 2 Surf, Surf With Quiksilver and all their members, all employees, all contractors, all consultants, all sponsors, brand partners and their members and agents or any school (here after in these terms and conditions below the company will be referred to as Surf Emporium) against and from liability for injuries, damages, loss or death arising from or in connection with my participation in, use of any equipment, travelling to or from, or presence at Surf Emporium. I waive any and all claims whatsoever which I may have arising there from or in connection therewith.

I hereby acknowledge that I have read and understood this indemnity and that I have entered into this indemnity freely, voluntarily and of my own volition. I furthermore acknowledge that all information contained in this indemnity is both true and correct.

I am over 18 years old and possess full legal capacity to sign this indemnity; or I am not yet 18 years old and as such I have not reached the age of majority. In light thereof, I am assisted by one of my parents / legal guardian who has signed this indemnity on my behalf, therefore providing me with the necessary consent to partake in the various activities, as specified hereinabove. Moreover, my parent / legal guardian confirms the accuracy of this form and considers it to be binding on themselves. This indemnity applies also in respect of any injury to such minor children.
I hereby confirm that I am not suffering from any disease and/ or temporary/ permanent physical impairment or any mental disease that may have an effect on my ability to participate safely in the activities mentioned hereinabove. If in the event I do have a disease and/ or temporary/ permanent physical impairment or any mental disease I will disclose this information Surf Emporium.
I hereby undertake not to consume any alcohol and/ or harmful substances prior to and/ or during the activities, as specified hereinabove.
I am aware that the activities specified hereinabove may be both dangerous and hazardous, and that by participating in the said activities, it may result in serious injury or death. I further acknowledge that whilst Surf Emporium takes every precaution to ensure the reasonable safety of its participants, I must exercise reasonable caution when I participate in any of the activities specified hereinabove. I furthermore acknowledge that I have made adequate enquiries and I am satisfied with the arrangements, safety precautions and facilities that are available vis-à-vis the activities specified hereinabove.
I hereby acknowledge that Surf Emporium, their instructors and their crew are exempt from accepting any liability and/ or responsibility for any injury and/ or damage caused whatsoever and/ or loss and/ or death arising from any negligence or any other cause suffered by myself, arising out of my participation in any of the activities specified hereinabove.
I hereby absolve, indemnify and hold harmless, Surf Emporium, from any and all liability and/ or damages and/ or death arising out of any incident and/ or accident which may take place whilst I am participating in any of the activities specified hereinabove.
I hereby authorize and give full permission to Surf Emporium, their sponsors and brand partners to utilize and make use of any photographs, moving pictures, visuals and/ or internet imagery captured of me whilst partaking in any event and/ or surfing lesson, and I furthermore acknowledge that I shall not be entitled to receive any payment and or remuneration thereof.
I agree to receive newsletters and/ or promotional materials from Surf Emporium.
I hereby acknowledge that I will be held liable for any damage to or loss of any equipment, stand- up paddleboards, paddles, surfboards, and/ or wetsuits whilst in my possession and/ or use. In light thereof, I acknowledge further that I will be held liable for the repair or replacement of said damaged or lost equipment as stated above and will moreover compensate Surf Emporium for such damage and/ or loss of equipment according to the repair, damage and theft policy schedule.
I acknowledge that all floors in the surf school are slippery when wet, and therefore I hereby absolve, indemnify and hold harmless Surf Emporium from any and all liability and/ or damages and/ or loss arising out of any accident or incident arising out of the wet floors.
I hereby acknowledge that Surf Emporium expressly reserves their right of admission.
I hereby acknowledge that if I do not complete this form, I will not be allowed to attend any surf lessons and or partake in any other activity with Surf Emporium.
I undertake to pay all fees due, owing and payable to Surf Emporium, in advance and without deduction or set-off. In addition to the afore going, I acknowledge that any fees paid to Surf Emporium are not refundable for any reason whatsoever.
I agree to abide by all rules and the code of conduct of Surf Emporium, and accept that in the event that I break any of the afore mentioned rules and/ or provisions of the code of conduct or disrupt the lessons or event, I will be immediately disqualified and dismissed from Surf Emporium without any refund of monies previously paid.
I acknowledge that on occasion, surf lessons or rentals may be affected by the shark spotters displaying the white flag, indicating the possibility of marine life activity inshore or the presence of a shark in the in the vicinity of Surfers Corner, Muizenberg Beach. I acknowledge that Surf Emporium endeavor to do their best to be flexible where possible however water access is beyond their control and in the best interest of safety for water users, I agree to adhere to the Shark Spotter and Surf Emporiums recommendation regarding water access.
I acknowledge that if a surf lesson or surf equipment rental has commenced and a duration of 15 minutes or more has passed, Surf Emporium reserves the right not to process a refund or reschedule the lesson.

I agreed to adhere to the shark spotters recommendations and will not enter the surf zone when the white shark flag is flying.
I agree to ensure my valuables are locked away in the provided lockers and I understand I must bring a lock to secure my locker.
This indemnity is the entire agreement between Surf Emporium, and I concerning the subject matter hereof, and no alteration to the terms or any subsequent agreement shall be of any force and effect unless reduced to writing and signed by both parties.