Registration Page 1 of 2

Sailor Information

Parent Email :

Junior Last Name :

Junior First Name :

Nickname :

Address :

City :

State :

Zip :

Sponsor (AYC Member) :

Relationship to Sailor :

Date of Birth :

Age at Junior Week :

Gender :

T-shirt size (adult sizes) :

Preferred Boat :

Sailing Experience (check all that apply :

Opti

Laser

420 Skipper

420 Crew

Junior Week Experience - Years Attended :

Swimming Experience : All sailors are required to be strong, confident swimmers and to demonstrate their swimming skills during an on site Swim Test.


Medical Information

Please list all physical or physiological impairments, use of corrective devices / appliances, or allergies. Include the use of eye glasses or contact lenses, hearing aids, artificial limbs or braces, pace makers, and diseases or disorders such as asthma, diabetes, epilepsy, hemophilia, allergies to bee stings or nuts, anxiety, etc. :

List current medications and dosages including emergency medications such as inhalers, insulin, epipens, etc :

Blood Type :

Date of last Tetanus shot :

Physician's Name :

Physician's Phone Number :

Insurance Company :

Policy Number :

Phone Number :

Dietary Restrictions

Please list any special dietary requirements / preferences whether for health, religious or personal preference reasons :


Emergency Contact

Emergency Contact (parent / guardian) :

Name :

Home Phone Number :

Cell Phone Number :

Work Phone Number :

Emergency Contact (other than parent / guardian) :

Name :

Relation :

Phone Number :


(Note ... after clicking on "Submit", you will be taken to Page 2 : Parent Volunteer Registration. We don't anticipate any difficulties, but just in case ... if you are not automatically taken to page 2, please email your registration info directly to Gigi & Al Daniel)

After hitting Submit, you will be taken to page 2 of Junior Week Registration : The Parent Volunteer Registration page.