YCSH registration 2013: Registration

Registration

Contact Info:

Parent/Guardian Name*
Child Name*
Winter Phone*
Summer Phone*
Cell #*
Email*

Winter Address:
Street Address*
City*
State*
Zip Code*
Summer Address:
Street Address*
City*
State*
Zip Code*

Class Options: (see list..)
Dates:
4 week - June 24-July 18
5 week - June 24-July 18 + 1 week during session 2
6 week - June 24-July 18 + any 2 weeks during session 2
7 week - June 24-August 9
3 week - July 22– August 9

LITTLE YAP

4 week ($770) 5 week ($970) 6 week ($1165) 7 week ($1340) 3 week ($590)

MATES

4 week FULL DAY ($1305) 4 week SAILING ONLY ($580) 5 week FULL DAY ($1640) 5 week SAILING ONLY ($720) 6 week FULL DAY ($1975) 6 week SAILING ONLY ($865) 7 week FULL DAY ($2300) 7 week SAILING ONLY ($1010) 3 week FULL DAY ($1000) 3 week SAILING ONLY ($435)

BEGINNING OPTI

INTERMEDIATE OPTI

INTRO to LASER and C420

4 week FULL DAY ($1305) 4 week SAILING ONLY ($665) 5 week FULL DAY ($1640) 5 week SAILING ONLY ($835) 6 week FULL DAY ($1975) 6 week SAILING ONLY ($1000) 7 week FULL DAY ($2300) 7 week SAILING ONLY ($1175) 3 week FULL DAY ($1000) 3 week SAILING ONLY ($510)

ADVENTURE SAILING with SUNFISH

INTRO to RACE TEAM

YCSH RACE TEAM

LASER and C420

More Info:

Private Boat Rack Rental:

Optimist, Sunfish and Kayak – $170/boat Laser and C420 – $200/boat Flying Scot – $300/boat

YCSH Boat Use Fee:

4 Week Rental ($225) 5 Week Rental ($280) 6 Week Rental ($335) 7 Week Rental ($390) 3 Week Rental ($170)

Meal Plan:

4 week session ($145.55) 5 week session ($181.90) 6 week session ($218.30) 7 week session($254.65) 3 week session ($109.15)

T-Shirt Size

Youth S Youth M Youth L Youth XL Adult S Adult M

Important: If you would like to request to have another child
in the same class as your child, please do so here:

Medical Info

Gender	Male Female
Height*
Weight*
Birthdate*
Emergency Contact 1 Name*
Emergency Contact 1 Phone*
Emergency Contact 2 Name*
Emergency Contact 2 Phone*
Physician Name*
Physician Phone #*
Health Insurance Carrier*
Insurance Policy #*
Insurance Group #
Insurance Subscriber's Name*

More medical info

Allergies*

Yes No

If yes, explain:

Other Medical Conditions?*

Yes No

If yes, check all that apply:

ADD/ADHD Convulsions/seizures Diabetes/hypoglycemia Hemophilia Asthma Heart Trouble Bee Sting Allergy Anxieties/Fears EpiPen Epilepsy Major Operations Other

If yes, explain:

Will your child be taking any medications?*

Yes No

If yes, please list:

Eyeglasses

Yes No

Contacts

Yes No

Hearing Problems

Yes No

Are there any activity Restrictions?*

Yes No

If yes, explain:

PAYMENT INFO:

Are you paying by check?* Yes No

If you are paying by check, payment must be received by April 30,2013.
Please address payments to: YCSH 9001 Sunset drive, Stone Harbor, NJ 08247

3.5% will be added for a processing fee

Credit Card Type
Credit Card Number
Credit Card Expiration Date	,
Billing Address:
Street Address
City
State
Zip Code

The information provided is correct and accurate to the best of my knowledge. I give permission for full participation in YCSH YAP, subject to limitations noted herin. In case of emergency, I understand every effort will be made to contact me. In the event that I can not be reached, I hearby give my permission to the licensed health-care practioner selected by the Director or designee to secure proper treatment, including hospitalization, anesthesia, surgery, or injections of medication for my child.
Agree

The applicant and/or his or her parent(s) or guardian(s) hereby agree to abide by the rules, regulations and instructions of the Yacht Club of Stone Harbor, its officers, Trustees and employees or representatives with respect to the conduct of classes, club property and facilities employed therein. Said applicant and his or her parent(s) or guardian(s) do hereby discharge and release the Yacht Club of Stone Harbor, its officers, trustees, employees, members and representatives of all liability, claims, demands and causes of action whatsoever, which said applicants and his or her parent(s) or guardian(s) has, have or may hereafter have out of or resulting from said classes or any part thereof, or in connection with any boat, dock, bulkhead, building, car or other equipment, or facility provided, classes or used in conjunction with said classes and groups, whether or not same may be owned, or controlled by them or any of their representatives. Said applicant, and his or her parent(s) or guardian(s) assume all risks of any injury or damage to person or property whether caused by negligence or otherwise, and agrees that no other agreement or representation, oral or written, shall in any way effect this release. If you use somebody else’s boat and damage does occur, it is your responsibility to pay for the damage. By executing this agreement, we agree that our child named in this agreement may be photographed and we release Yacht Club of Stone Harbor from any and all liability associated with such photography.
Agree