Reservations Long Form

Your Information:

First Name:

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Last/Surname:

*

Company:

Age:

5-1718-2526-3536-4546+ *

Billing Address:

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City:

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State / Provence:

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Zip / Postal Code:

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Country:

USAAustraliaBrazilCanadaJapanChinaS. KoreaUnited KingdomFranceItalySpain---AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCape VerdeCaribbean NetherlandsCayman IslandsCentral African RepublicChadChileChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo, Democratic Republic ofCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelJamaicaJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia, Federated States ofMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian Territory, OccupiedPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussian FederationRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint-Martin (France)Saint-Martin (Pays-Bas)SamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakia (Slovak Republic)SloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSri LankaSt. Pierre and MiquelonSudanSurinameSvalbard and Jan Mayen IslandsSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandThe NetherlandsTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and Futuna IslandsWestern SaharaYemenZambiaZimbabwe *

Home Phone:

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Mobile Phone:

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Work Phone:

FAX:

Email Address:

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Your Destination

Please check the countries you would like to include in your surf clinic:

Island of MauiOahu, HawaiiGold Coast Australia & Upper NSWRequest for Nancy to bring Aloha Surf Clinics to your areaNamotu, Fiji (not for beginners and allow 3-6 months advanced booking)

Travel Arangements

Would you like suggestions for your accomodations?

—Please choose an option—HotelMotelCondo/ApartmentAirbnbYouth Hostel

Budget:

Arrival Date:

Departure Date:

Airline:

Water Experience

For Nancy Emerson School of Surfing, Aloha Surf Clinics or Gold Coast Australian School of Surfing to provide you with the most effective coaching, teaching and for you to receive the best out of your surfing clinic, lessons or book a surf guide.

PLEASE answer the following questions truthfully regarding your swimming experience and ability in the ocean.

Basic (I can float and feel comfortable in the water, 250 meters/100 yards in a pool or lake)Intermediate (I can identify undertow and rip currents from the shore, and know how to get out of them. When in the water, I can swim 500 meters/250 yards comfortably in a pool or lake.)Advanced (You're a Water Baby!)

Do you have any feelings about the ocean which make you feel nervous about the Ocean?

Health

Do you have any physical ailments or injuries ie. back, knee, shoulder, neck pain?

YesNo

If Yes, please provide details:

Have you had any experiences during your childhood or adult life that have left you feeling uncomfortable with "Our Mother Ocean"?

Surf Experience

Have you ever surfed before?

noneoncea few timesmonthlyall year round

What is your ability?

First Time BeginnerAdvanced BeginnerIntermediateSeasonedCompetitve

Where have you surfed, what size of waves have you ridden?

What size and shape of surfboard have you used or what are you currently using?

Long BoardMini-MalShort BoardBody Board

Are you bringing your own boards or do you want to use our equipment during your clinic or classes?

I'm bringing my own boardI want to use your equipment

Choose Instructor Classes

Your choice of instructor (refer to rate page)

Instructor (certified)Chief InstructorNancy Emerson (if available)Combination

For combination please add your preference, ie. 1 day Chief Instructor and 2 days Nancy Emerson

Additional Information

Are there any other details that the Nancy Emerson School of Surfing needs to know regarding your intended trip to make things easier or more comfortable for your Surfing Experience?

What type of lessons or surf clinic are you interested in?

What type of lessons or clinic are you interested in?

Group 2 hourPrivate 2 hourPrivatePrivate w Chief instructorSemi-private 3-5 Day ClinicPrivate Clinic - With Chief InstructorWorking with Nancy EmersonWorking with Surf Guide

How many will be in your group (3-5 people)?

Ages?

Height, Weight of each person surfing and their name?

Thank you very much for filling out our reservation form which will greatly help us in assisting in planning your surfing clinic or class with Nancy Emerson School of Surfing on Oahu, Aloha Surf Clinics with Nancy Emerson on Maui or the Gold Coast Australian School of Surfing in Queensland, Australia.

PLEASE refer to the Rate Page on the Web site for questions to our options or Nancy can help in creating a combination for your surfing with them..