2011 LAYC Summer Sailing Program Application

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2011 LAYC Summer Sailing Program Application Powered By Docstoc
					           2011 LAYC Summer Sailing Program Application

Last Name ___________________First Name ______________DOB_____

Address_____________________________________________________

City__________________________________ State _____Zip ___

Mother’s Name__________________ Telephone______________

Father’s Name___________________ Telephone_______________

H Telephone_________________________ Email                                      __

Emergency Contact______________ Telephone_________________

Please check the session(s) and class(es) you wish to enroll in:
_Session 1 (June 27nd to July 8th)        _ Session 2 (July 11th to July 22nd)

___Monday Wednesday Friday                    ___Monday Wednesday Friday
___Tuesday Thursday Friday                    ___Tuesday Thursday Friday

___Session 3 (July 25th to August 5th)

___Monday Wednesday Friday
___Tuesday Thursday Friday



Method of payment ($500.00 per session):
Cash $_______
Check Enclosed $________ Ck #______
Scholarship:     Full        Partial (for details inquire at the LAYC office)
Credit card payment option available

Student Shirt Size: (Circle One)
Child:     Small        Medium

Adult:       Small               Medium              Large        X- Large
                         LAYC Policies & Disclaimers
Privacy Policy
The Los Angeles Yacht Club respects your privacy and is committed to protect the
personal information you share with us. With that in mind, we have established and
implemented information handling practices for www.layc.org that we believe are
consistent with the highest standards and best practices of organizations doing
business on the Internet.
The Los Angeles Yacht Club will not disclose your Personal Information to third
parties. All information provided will be collected, viewed, and used by only the Los
Angeles Yacht Club Sailing Office and Junior Sailing Director.
We exercise care and due diligence in managing, transmitting, and securing Personal
Information once we receive it. Your Personal Information is protected by safeguards
that are appropriate to the sensitivity of the information. The Los Angeles Yacht Club
safeguards the security of the information you send us with physical, electronic, and
managerial procedures. Your information is secured from unauthorized access from
the Internet through industry-standard firewall technology.
The Los Angeles Yacht Club reserves the right to amend this policy from time to
time. If we make any changes to this policy, we will make that information available
by posting a notice to this site.(____) *Initials

Contact Information
If you have any questions or concerns about our collection, use, or disclosure of your
Personal Information, please call the Office at 310.831.1203.

Refund Policy
For reservations cancelled prior to June 10, 2011, a Full Refund will be granted. A 50%
refund will be granted for reservations cancelled 15 days prior to the start of your class. Please
contact the Office for more details. (____) *Initials

Medical and Liability
AUTHORIZATION TO CONSENT TO TREATMENT OF A MINOR
           As the parent or guardian of the registered sailor, I do hereby consents to any emergency x-ray,
anesthetic medical or surgical diagnosis or treatment and hospital care which is deemed advisable
by, and is to be rendered under the general of special supervision of any physician and surgeon
licensed under the provision of the Medical Practice Act.
           It is understood that this authorization is given in advance of any specific diagnosis, treatment, or
hospital care being required but is given to provide authority and power on the part of our aforesaid
agent(s) to give specific consent to any and all such diagnosis, treatment or hospital care which the
aforementioned physician in the exercise of his best judgment may deem advisable; and neither
said agent or any organization involved assumes any financial responsibility for exercising this
action.
           This authorization is given pursuant to the provisions of Sections 25.8 of the Civil Code of California.
Parent's Consent and Waiver of Liability, Assumption of Risk, & Indemnity Agreement
The undersigned parents or legal guardians (hereafter referred to in the singular) of (herein referred
to as the "Child"), request that the child be allowed to participate at any Los Angeles Yacht Club
facility in any Junior Activity (herein referred to as "the activities"). This agreement shall remain in
effect until Los Angeles Yacht Club Junior Committee receives written notice of the cancellation of
the consent or until the end of the activities described above.
           In return for the child being permitted to take part in the activities and to use the facilities and
property of Los Angeles Yacht Club each of us makes the following promises and warrants the truth
of the following facts:
           1) I am familiar with the programs included in the activities, and I understand officers and
employees of Los Angeles Yacht Club are available to discuss the activities if I should wish additional
information. I also understand I am solely responsible for the arrival and departure of my child at
the beginning and end of each day's Activity. I will not allow my child to remain on the premises of 1


Page 1 of 2
Los Angeles Yacht Club after each day's program without appropriate supervision or the written 2
permission of the Yacht Club. I agree Los Angeles Yacht Club will have no responsibility for the 3

supervision of my child at times other than during the scheduled activities. I will inform my child
that he/she is expected to cooperate with, and follow the directions of, the persons in charge of the
activities and to act in a manner consistent with the spirit of good sportsmanship and respect for the
rights of others.
           2) My child is in good health, and I know of no reason why he/she would be incapable of
participating in the activities. My child knows how to swim. I will immediately notify the designated
Los Angeles Yacht Club supervisor, if a change in my child's health or other condition would affect
my child's ability to participate in the activities.
           3) WAIVER OF LIABILITY I waive and release any right I, my heirs, distributees, guardians, legal
representatives and assigns may have or acquire to make a claim against, sue, attach the property
of or prosecute Los Angeles Yacht Club or any of its members, directors, officers, agents, employees
and affiliated organizations (herein referred to as "the releasees") for monetary damages caused by
injury to my child or damage to the property of my child or myself arising from my child's
participation in the activities and use of the facilities and property of Los Angeles Yacht Club,
whether or not the injury or damage results from the negligence or other action, except intentional
acts, of any of the releasees
           4) ASSUMPTION OR RISK I am aware that the activities may involve maneuvering a boat, sailboard
or other watercraft on deep waters in potentially hazardous conditions which may include, among
other things, strong wind and high waves, sudden and unexpected immersion in deep waters and
collision with other watercraft or stationary objects such as docks, pilings and buoys. With
knowledge of the dangers involved, I voluntarily ask that my child be allowed to take part in the
activities.
           I ACCEPT ANY AND ALL RISKS TO MYSELF AND MY CHILD OF INJURY, DEATH AND
PROPERTY DAMAGE ARISING FROM PARTICIPATION IN THE ACTIVITIES AND THE USE OF THE
FACILITIES AND PROPERTY OF LOS ANGELES YACHT CLUB, WHETHER OR NOT CAUSED BY THE
NEGLIGENCE OR OTHER ACTION, EXCEPT INTENTIONAL ACTS, OF ANY OF THE RELEASEES.
           5) INDEMNITY AGREEMENT I agree to indemnify and hold the realeasees harmless from any loss,
liability, damage or cost, including reasonable attorneys fees, they may incur due to my child's
participation in the activities and use whether or not such loss, liability, damage or cost results from
the negligence or other action, except intentional acts, of any of the releases.




Emergency Contact:________________________________________________________________

Daytime Phone: ___________________________________________________________________

Cell Phone:_______________________________________________________________________

Medical Concerns / Known Allergies:___________________________________________________

_________________________________________________________________________________

Insurance Provider:________________________________________________________________
I HAVE CAREFULLY READ THE MEDICAL AND LIABILITY AGREEMENT AND THE
POLICIES AND DISCLAIMERS FORM AND FULLY UNDERSTAND THE CONTENTS OF BOTH.
I AM AWARE THE AGREEMENT INCLUDES A WAIVER OF LIABILITY, AN ASSUMPTION OF
RISK, AN AGREEMENT BY ME TO INDEMNIFY THE RELEASEES, PRIVACY POLICY, AND
REFUND POLICY AND I AGREE TO IT OF MY OWN FREE WILL.


_________________________________________________________________________________________________________

*Signature of Parent/ Legal Guardian               *Printed Name                             *Date




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                   Los Angeles Yacht Club Junior Sailing Program
                       Minor’s Health History - Parent’s Report

Minor’s Name: __________________________________________________________

Date of Birth: ___________________________               Sex: ____ Male       ____ Female

Does your child have the following?                             Details / Limitations

Seizures                           _____No _____Yes ______________________________________
Heart defect or disease            _____No _____Yes ______________________________________
Diabetes                           _____No _____Yes ______________________________________
Bleeding / clotting disorder       _____No _____Yes ______________________________________
Asthma                             _____No _____Yes ______________________________________
Serious allergies: Insect stings   _____No _____Yes ______________________________________
                   Penicillin      _____No _____Yes ______________________________________
                   Other drugs     _____No _____Yes ______________________________________
                   Food            _____No _____Yes ______________________________________
                   Other           _____No _____Yes ______________________________________
Muscle, bone or joint problems _____No _____Yes ______________________________________
Previous injury still affecting    _____No _____Yes ______________________________________
Loss of consciousness              _____No _____Yes ______________________________________
Physical limitations               _____No _____Yes ______________________________________
Surgery in the last year           _____No _____Yes ______________________________________
Special fears or conditions        _____No _____Yes ______________________________________

Note: If you answered “Yes” to any of the above, you must provide a doctor’s release
      before your child will be allowed to participate in the Junior Sailing Program.

LAYC reserves the right in its sole discretion to decline any participant for safety reasons.

Is there any thing else we should know about your child? ________________________________
_______________________________________________________________________________________

I certify that the above information is true, correct and complete.


_______________________________________        ___________________________
Signature of Parent or Guardian                          Date


___________________________________________
Print Name

				
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