Name of Student ______________________________ Date of Birth ___________ Weight _______ lbs.

Address ___________________________________________________________________

City, State, Zip ____________________________________________________________________

Father's Name ________________________________ Mother's Name_________________________________

Home Phone (_____)__________________________ Home Phone (_____) _______________________

Work Phone (_____)__________________________ Work Phone (_____)________________________

Can the student complete our swim test? (Swim 50 feet in salt water while wearing a PFD) Yes  or No

What prior sailing experience does the student have? _________________________________________________

Course Preference:
July 15-19 ____
July 22-26 ____

Please mark your preferred course(s) with an  X.  If alternate dates will work, mark them with an  A.  Early registrations will have priority, but we will try to accommodate as many as possible. If a conflict arises, we will call to discuss solutions.

Course Pricing: $150.00 per student. Price includes 30 hours of sailing instruction, participation tee shirt, prizes and awards. Please pay by check made payable to BYC Youth Sailing. Include your check with the completed registration forms.

How did you learn about the BYC Youth Sailing Program? _______________________________________________

Who should be contacted in case of an emergency during class hours?

Father Mother Other Person: Name ___________________________ Relationship __________
Phone (____)_____________ Work (____)______________

Other numbers to try (Cell Phone, Beeper, etc): (____)_____________ (____)______________

Family Physician Name _______________________________________ Phone (____)______________

Date of last Tetanus Shot __________________ Blood Type (If you know for sure) ___________________

Allergies to food, drugs or insects _________________________________________________________________

Medications taken regularly ______________________________________________________________________

Does the student have any physical limitations or chronic ailments that might limit full participation in the Program?

Yes No If yes, please describe_________________________________________________________

Are there any conditions or concerns with which Program Staff should be familiar? Yes No

If yes, please describe __________________________________________________________________________

*We will take every precaution to keep students safe, but kids will be kids, and we need to be prepared. We will find a way to accommodate students who have special needs, but will need guidance from parents.