The Sailing Center at RYC 2009 Youth Sailing Program

							The Sailing Center at RYC 2009 Youth Sailing Program
                REGISTRATION FORM
Student’s Name:                                                   Birthdate __/__/__ Age (as of 6/22/09)
Address                                                           City                         Zip
Father’s Name                                                     Mother’s Name
Phone (home)                     (work)                           Phone (home)                (work)
Cell Phone:                                                       Cell Phone:
Email                                                             Email

High School Sailors only:
Student’s Email                                                   Students Cell Phone

RYC Member:          yes    no                                    RYC Member #
Describe previous experience in sailing programs


I have read, understand and will adhere to the RYC Youth Sailing Guidelines (back of Calendar)
Student Signature                                        Parent Signature

                          2009 RYC Opti Race Team Instruction
  Session 1 : June 23- July 24       Session 2 : July 27-Aug 14 ( see Calendar under Race Teams )
 Using privately boat:                                                                       Fee      Total
 Advanced Opti RT session 1                                                                 $350.00
 Advanced Opti RT session 1non-member                                                       $495.00
 Green Fleet Opti RT Session 1                                                              $350.00
 Green Fleet Opti RT Session 1 non-member                                                   $495.00
 Green Fleet Opti RT Session 1 with LTR class                                               $220.00
 Green Fleet Opti RT Session 1 with LTR class non-member                                    $315.00
 Advanced Opti RT session 2                                                                 $160.00
 Advanced Opti RT session 2 non-member                                                      $240.00
 Green Fleet Opti RT Session 2                                                              $225.00
 Green Fleet Opti RT Session 2 non-member                                                   $340.00
 Green Fleet Opti RT Session 2 with LTR class                                               $161.00
 Green Fleet Opti RT Session 2 with LTR class non-member                                    $250.00
                                                                                              Total   $
Using RYC Optimist :
Subject to availability: please contact Youth Sailing Director at 342-5511 ext 13
                                                                            Cost per
                                                                               Day
 RYC Opti Charter Fee per half day                                             $10.00
 RYC Opti Charter Fee per half day non-member                                  $15.00

 Green Fleet instruction / coaching cost per 1/2 day                         $18.00
 Green Fleet instruction / coaching cost per half day non-member             $27.00
                                                                               Total    $

Please charge my RYC Account #                   Signature

Make checks payable to: Rochester Yacht Club                      RYC accepts: VISA / MC and AmEx

Mail to:        5555 St. Paul Blvd                       Card #:                                              exp date___/___/___
                Rochester, NY 14617

                                             Signature:
Confirmation and further information will be mailed to all registrants
HEALTH AND MEDICAL INFORMATION
Participant’s Name:
Sex:
Student’s date of birth: Grade Entering

IN THE EVENT OF AN EMERGENCY, NOTIFY:
First Contact
Name:
Relationship:
Home Phone:                     Work Phone:                                                   Cell Phone
Second Contact
Name:
Relationship:
Home Phone                      Work Phone:                                                   Cell Phone:

MEDICAL INFORMATION
Primary Care Physician Name
Phone:
Health Insurance Provider:
Policy Number:
Date of most recent tetanus shot:___/___/____
Give all information needed to provide as safe and as full participation as possible and explain any YES answers below:
Asthma: Yes ( ) No ( ) Heart Disease: Yes ( ) No ( )      Leukemia: Yes ( ) No ( )         High Blood Pressure: Yes ( ) No ( )
Cancer: Yes ( ) No ( ) Convulsions: Yes ( ) No ( )         Diabetes: Yes ( ) No ( )        Hemophilia: Yes ( ) No ( )
Explain:
Does participant take prescription drugs regularly? Yes ( ) No ( )
Explain:
Does participant require any special accommodations (glasses, contacts etc.) in order to participate fully in any activity?
Yes ( ) No ( ) Explain
Special learning or behavioral needs     Explain:

Allergies Yes ( ) No ( )
Please list:

Statement of Medical Conditions and Consent for Medical Treatment
I attest to the fact that the above named child is in good health and that there is no medical condition that precludes involvement in
any of the programs of the Rochester Yacht Club (RYC). I grant permission to RYC and its employees to administer medical
treatment that may be deemed necessary in the event of injury or illness.
Signature:
Date:

Consent, Waiver and Indemnity Agreement
THIS FORM MUST BE READ AND SIGNED BEFORE ANY STUDENT PARTICIPATES IN ANY ROCHESTER YACHT
CLUB SAILING COURSE. BY SIGNING THIS AGREEMENT, THE PARENT/GUARDIAN AFFIRMS HAVING READ IT.
I hereby give permission for                                                 (Print child’s name) to participate in all programs and
activities of the Rochester Yacht Club, including transportation to and from events, if needed. I understand that my child must
pass any test necessary in order to participate in a program. I understand that there are risks inherent in sailing, sailboat racing, and
other water-based and land-based programs and that accidents can occur on the water as well as on land during any RYC program.
Such accidents can result in serious injury and death. I do for my child, myself, and our personal representatives, family, heirs and
assigns, knowingly and freely waive all claims against and release and discharge RYC and its officers, directors, agents,
employees and volunteers from any and all liability, loss, damage and expense which may result from participation in RYC
programs.

RYC reserves the right to photograph program participants for publicity purposes.

Signature:
Date: