2011se_entryform

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2011 SE v006 BA & TMc -- 2011-02-24 Page1 of 6

Presents the

2011 SOUTHEAST REGIONAL

SURFING CHAMPIONSHIPSScheduled Dates: April 16-18, 2011

Anastasia State Park, St Augustine, FL

Qualifier to the 2011 THE EASTERNS

Contest Headquarters: Mention ESA for discountThe Hilton Garden Inn401 A1A Beach Blvd.St. Augustine, FL 320801-800-762-5311

Information: Contest Director Burgess Autrey, Southeast Region DirectorWebsite: http://www.surfesa.org/ email: [email protected]

Eligibility: Certified district representatives who are members in good standing of theESA through SEPTEMBER 30, 2011. A contestant applying for entry whosemembership expires before September 30, 2011 must renew his or her membershipwith entry fee. Entry will be rejected and the slot passed on if this procedure is notfollowed. Entry is open only to those competitors who are in full compliance with theESA Competition Code (rev. Jan 1, 2006.)

Entry Instructions: Please complete the attached entry form and forward with check

for entry fee to your LOCAL DISTRICT DIRECTOR IMMEDIATELY. Addresses oflocal District Directors are on listed later on this application.

NOTE: If your membership expires before September 30, 2011 please fill out themembership form and attach a separate check for a membership renewal form.

Alternates: Please follow same instructions as above. If you have a slot in onedivision and are an alternate in another division, fill out separate entry forms and attachseparate checks. Note: A second entry form can be downloaded from the ESAcompetition website at www.surfesa.org/content/section/6/28/

Entries not received by your Local District Director on/or before Friday, March 07,2011 will not be accepted or you will be considered as a late paid alternate.

From: Mary Ann MangiacapreESAs Competition Director:Competitors are responsible for using the proper equipment and abiding by the ESARules of Competition. Competitors are responsible for schedule changes, as theposted schedule is always subject to change due to weather conditions. There will beno refunds to no shows in a posted heat. Competitors are expected to conduct

themselves in a sportsmanlike manner at all times.
http://www.surfesa.org/content/category/6/31/41/http://www.surfesa.org/content/category/6/31/41/http://www.surfesa.org/content/category/6/31/41/mailto:[email protected]:[email protected]:[email protected]:[email protected]://www.surfesa.org/content/category/6/31/41/


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EASTERN SURFING ASSOCIATION2011 SOUTHEAST REGIONAL SURFING CHAMPIONSHIPS

AGE DIVISIONS FOR THIS EVENT (age as of January 1, 2011)

Menehunes (11 & under) Girls (14 & under) Menehune Longboard(Boys/Girls 14 & under) Junior Women (15-17) (Boys/Girls 14 & under)

Boys (12-14) Women (18-29) Junior Longboard (15-17)Junior Men (15-17) Ladies (30+) Mens Longboard (18-34)Men (18-24) Masters Longboard (35-49)Masters (25-34) Menehune Bodyboard Legends Longboard (50+)Senior Men (35-44) (Boys/Girls 14 & under) Womens Longboard (29 & undeGrandmasters (45-54) Open Bodyboard Ladies Longboard (30+)Legends (55-64) (M/F all ages)Grand Legends (65+)

Open Shortboard

(M/F all ages)

Entries must be received by your Local District Director on/or before Friday, March 07, 2011:

Local District Directors addresses:

ESA-NGFL District

Vince RileyPO Box 513Shalimar, FL 32579

ESA-TCFL District

Cheryl & Charles Williams1571 3rd AvenueVero Beach, FL 32960

ESA-CFL DistrictRob Henry & Tom Evans385 Hibiscus BlvdMerritt Island, FL 32952

ESA-WFL DistrictGreg Agerskovc/o The Surf Shack Surf Shop5210 Gulf Blvd.St. Pete Beach, FL 33706

ESA-FCFL DistrictRick Chapman & Steve Sugarc/o Pipeline Surf Shop2022 1st Ave.Fernandina Beach FL 32034

ESA-NFL District

c/o Co-Dir Kathy Austin12361 Burgess Hill Dr.Jacksonville, FL 32246

ESA-SAFL DistrictWill Gresham103 Alicante RdSaint Augustine, FL 32086

ESA-PBFL Districtc/o Co-Dir Shellie Chiet1511 Seabrook RoadJupiter, FL 33469

ESA-AL DistrictChuck Barnes14178 River Rd. Unit CPerdido Key, FL 32507

ESA-NCFL DistrictGene Verano & Ryan MarksPO Box 1551New Smyrna Beach, FL 32170

ESA-SFL Districtc/o Dutch Schorn1701 North Federal HwyFort Lauderdale FL 33305


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EASTERN SURFING ASSOCIATION2011 SOUTHEAST REGION SURFING CHAMPIONSHIPSCheck-in Saturday, April 16 -18, 2011 - 7:30 am SHARP!

SEE NEXT PAGES FOR MANDATORY SIGNATURES!

Contest Headquarters (Ask for ESA discount):The Hilton Garden Inn, 401 A1A Beach Blvd., St. Augustine, FL 32080, 1-800-762-5311,

Contest Information: Burgess Autrey, SE Region Director, email:[email protected] http://www.surfesa.org/

Host District Directors: Will Gresham ESA SAFL Director

Time/Heat Information: Posted on-line at: http://www.SurfESA.org/

Entry Fees: $95.00 First Event / $60.00 Each Additional Event

INVITED COMPETITORS & ALTERNATES: DO NOTcombine entry fees and membership fees in one check (attachseparate checks to each form). All mailed checks will be deposited to allow time for checking clearing. CHQ will issueany refund due to a non-slotted competitor within 30 days from Friday, March 04, 2011.

Two part OFFICIAL ENTRY FormESA 2011 SERSCEntry Deadline: Midnight, Friday, March 07, 2011

It must also include a signed hold harmless form that is on the next pageA contestant applying for entry whose membership expires before September 30, 2011 must renew membership.

ESA District: __________________________Members current expiration date is: ___________________________

Name: _________________________________________________________________________________________

Age: (as of 1/1/2011) _______________________ Date of Birth (mm-dd-yyyy): _________________________________

Mailing Address: _____________________________________________ City: ______________________________

State: __________________ Zip: ___________________ Telephone (Home): _____________________________

E-mail Address: __________________________________________________________________________________

Emergency Contact-Name and Phone Number: _________________________________________________________

Any known allergies to medications or other pertinent health issue: ___________________________________________

_________________________________________________________________________________________________________________________

Name of 1st Event ($95): ___________________________ Name of 2nd Event ($60): ________________________

Name of 3rd Event ($60): ___________________________ Name of 4th Event ($60): _________________________

T-Shirt Size: Adult sizes only, please circle your size: (Sm) - (Med) - (Lg) - (XLg) or (

First Entry Fee ($95)

Additional Entry Fees ($60 each Divs.) $_______

Total fees enclosed (make payable to ESA) $________________________
mailto:[email protected]:[email protected]:[email protected]://www.surfesa.org/content/category/6/31/41/http://www.surfesa.org/content/category/6/31/41/http://www.surfesa.org/content/category/6/31/41/http://www.surfesa.org/content/category/6/31/41/http://www.surfesa.org/content/category/6/31/41/http://www.surfesa.org/content/category/6/31/41/http://www.surfesa.org/content/category/6/31/41/http://www.surfesa.org/content/category/6/31/41/mailto:[email protected]


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EASTERN SURFING ASSOCIATION

2011 SOUTHEAST REGIONAL SURFING CHAMPIONSHIPSHOLD HARMLESS RELEASE MUST BE SIGNED AND RETURNED

WITH ENTRY FORM IF ENTERING BY MAIL

HOLD HARMLESS RELEASE: This release bars your rights to recover damages in the case of an accident injuring you.READ BEFORE SIGNING!In applying to the ESA surfing tournaments, I promise to Inspect the contest site, and assure myself that the area is safefor surfing, and further agree that I will not surf in the contest unless I am satisfied that the area and conditions are safe forsurfing purposes. In exchange for the Eastern Surfing Associations accepting my entry form, I voluntarily agree tassume all risks incident to the sport of surfing, I fully understand and comprehend the dangers of surfing created by thesharp edges and fins along with the natural buoyancy of a surfboard when they are acted upon by the powerful forces ofthe ocean and ocean waves. With full knowledge, comprehension and understanding of these dangers, I voluntari

accept and assume all risks involved in the spirit of competitive surfing. I will further read and comply with all the ESrules and regulations noting existing weather conditions, and do agree that I voluntarily assume all risks arising fromconditions related to use of the contest site by myself and others. In consideration of your acceptance of my entry,intend to be legally bound, hereby, for myself, my heirs, executors and administrators, hold harmless and release andforever discharge the Eastern Surfing Association, its directors, ESA St .Augustine (SAFL) District, Anastasia State Park,St. Johns County, FL, the State of Florida, all ESA National Sponsors and local sponsors, their members, agents and anyofficials connected with this competition, from all liabilities for injuries and damages whatsoever, arising from my presenceor participation in the above described event and do hereby grant the sponsors such release as described herein. acknowledge that I have read and understand all of the above.

CONTESTANTSNAME (Please Print): _____________________________________________________________________________

CONTESTANTSSIGNATURE: ______________________________________________________________ DATE:______________

FOR CONTESTANTS UNDER 18 YEARS OF AGE:

NAME OF PARENTOR GUARDIAN (Please Print): ______________________________________________________________________

SIGNATURE

OF PARENTOR GUARDIAN: ____________________________________________________________ DATE:______________

I HEREBY CERTIFY that I am the parent or guardian of the surfer named above, and do hereby give my permissionwithout reservation and with full understanding and comprehension of the foregoing agreement to hold theaforementioned organization and governmental entities harmless any and all liabilities including any such injuries whichare alleged to have occurred as a result of negligent failure of ESA officials, judges, and directors to properly supervisecontestants in the course of competition.


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MEMBERSHIP APPLICATION

Current Expiration Date: __________________________________________________________________________

Name: __________________________________________________________ Birth Date: __________________

Mailing Address: ________________________________________________________________________________

City: _____________________________________ State: __________________ Zip: ___________________

Phone: _(______)__________________ Email: __________________________________ District: _________

Family Memberships: Please list names, date of birth and divisions for each additional member (or list onadditional sheet.)

Shortboard (check one)

Menehunes (11 & under)(Boys/Girls 11 & under)

Boys (12-14) Junior Men (15-17) Men (18-24) Masters (25-34) Senior Men (35-44) Grandmasters (45-54) Legends (55-64) Grand Legends (65+) Girls (14 & under)

Junior Women (15-17) Women (18-29) Ladies (30+)

Open Shortboard(M/F all ages)

Longboard (check one)

Menehune(Boys/Girls 14 & under)

Junior (15-17) Mens (18-34) Masters (34-49) Legends (50+) Womens (29 & under) Ladies (30+)

Bodyboard (check one)

Menehune(Boys/Girls 14 & under) Open (M/F all ages)

Membership (check one)

New Member Renewal Member

Expiration Date:________

Membership Type (check one)

Competition: $40includes two divisions / $5each extra division

General (non-competitive)$20

Family: $50 base plus

$5 per competition divisionfor each family memberAt least one person mustcompete(List on additional sheet)

Lifetime: $1000 individuaIncludes 4 divisions

As a member of ESA, youre automatically qualified to receive a FREE one-year subscription to Transworld Surfmagazine, bringing you the best surf coverage on the planet each month. You WILL NOT be billed for anything.

[ ] Yes, please send me a FREE one-year subscription to Transworld Surf magazine.[ ] No thanks, I would prefer not to receive a FREE one-year subscription to Transworld Surf magazine.

Make check payable to: E S A and mail to:

ESA HeadquartersP.O. Box 625Virginia Beach, VA 23451

TOTAL MEMBERSHIP FEES ENCLOSED: $___________________________


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2011 SE v006 BA & TMc -- 2011-02-24 Page6 of 6

Presents the

EASTERN SURFING ASSOCIATION2011 SOUTHEAST REGION

SURFING CHAMPIONSHIPSQualifier to the 2011 THE EASTERNS

Anastasia State Park, St. Augustine, FL

2 0 1 1 E n t r y F o r m

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EASTERN SURFING ASSOCIATION

2011se_entryform

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