Adult Learn-to-Sail Registration

Information and registration for 2019 classes will be released in the coming months. Please check back soon!

Date of Sailing Class
Date Format: MM slash DD slash YYYY
Name*
First Last
Date of Birth*
Date Format: MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Phone (work)
Email*
Sailing Experience*
- None
- Limited
- Can sail alone
- Regatta experience
Emergency Contact
Name*
First Last
Phone*
Medical Info
List any medical factors that would be pertinent in emergency treatment.
i.e. allergies, blood type, history of seizures, and any current medication.
Date of last tetanus injection (if known)
Date Format: MM slash DD slash YYYY
Please explain any physical limitations that might prevent you from fully participating in the course.
Can you complete a swimming test?*
Using any stroke, swim approximately 50 yards, tread water for 20 seconds and put on a PDF.
- Yes
- No
Preferred Family Physician (full name)*
Physician Phone*
Health Insurance
Name of Insurer
Policy Number
IMPORTANT
This part must be complete for attendance.
Permission to Provide Necessary Treatment of Emergency Care:

I hereby give permission to the medical personnel selected by the program director to order x-rays, routine tests, or treatment; to release any records necessary for insurance purposes; and to provide or arrange necessary related transportation for me. If I am unable to communicate and my emergency contact cannot be reached in an emergency, I hereby give permission to the physician selected by the program director to secure and administer treatment, including hospitalization, for me.
Signature*
Date*
Date Format: MM slash DD slash YYYY

Concord Yacht Club

Adult Learn-to-Sail Registration

Emergency Contact

Medical Info

Health Insurance

IMPORTANT

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