CLASS REGISTRATION FORM Participant s Name: Today s Date: Address: City: State: Zip Code: Date of Birth: Age: Email: Home Phone: Mobile Phone: Parent/Guardian Name: Daytime Phone: Parent/Guardian Name: Daytime Phone: How did you hear about the Learn to Sail program? (Circle one) Newspaper School Magazine Library SSC Event DockTalk Friend/Family Website Other Sailing Experience: Novice (Never Sailed Before) Beginner (I can rig my own boat) Intermediate (I m ready to race) (Circle One) Class Dates: 2 classes per Day Please use a separate form for each class Morning Session: 8:00 am to 12:00 pm Afternoon Session: : 1:00 pm to 5:00 pm June 3-7 Novice Beginner Intermediate June 10 14 Novice Beginner Intermediate June 17 21 Novice Beginner Intermediate June 24 28 Novice Beginner Intermediate July 1-5 No Classes No Classes July 8 12 Overnight Sail Camp Register at www.sailcamp.org July 15 19 Novice Beginner Intermediate July 22 26 Novice Beginner Intermediate July 29 Aug. 2 Novice Beginner Intermediate Aug. 5 9 Novice Beginner Intermediate Aug. 12-16 Novice Beginner Intermediate If interested in additional class dates, please inquire at learntosail@stocktonsc.org. ** The Stockton Sailing Club reserves the right to change classes/levels based on the needs and abilities of Learn to Sail Participants and Instructors. Every effort will be made to reassign students to a comparable class with as much advance notice, as possible. Participant Requirements Sailors need to be 8 to 17 years old and weighing at least 60lbs and able to swim. Monday classes are mandatory for Novice sailors. Sailors need to be dropped off promptly, at the classroom on the point by the cranes. Sailors wanting to continue to advance their skills are encouraged to return for additional courses. All participants must behave in a respectful manner. This is an instructional program, to teach boating safety and the fundamentals of sailing. This is not an alternative to parental supervision. We reserve the right to dismiss any child, if they cannot respect the basic rules of the club and the program. Parents: Please obey the 10 mph speed limit on the property. Please arrive 5 minutes prior to the end of class to pick up your child. 1
Registration Form Continued: Participant s Name: Tuition: Novice (First timer) $50 (Repeat Novice) $135 Class Tuition $ Beginner $135 *SSC Youth Membership $ 15.00 Intermediate $135 Total Due Now $ SSC members may charge tuition fees to their account. Account # Member Last Name: Name on Card Please make check payable to: Stockton Sailing Club Full payment may be paid by check, Visa or MasterCard credit card. Visa/MC # Amount to be charged $ Billing Address Billing Zip Code Expiration Date 3 Digit V-Code Signature (Required) Returned checks will be charged a$25.00 insufficient funds fee. Tuition payment is required at time of registration. Class registration is on a first come first served basis. Cancellation less than ten days prior to class start date will result in forfeiture of tuition paid. *Membership/Insurance* The State of California Department of Boating and Waterways Grant requires all participants be covered by the appropriate insurance that specifically indemnifies the State and its Department of Boating and Waterways. Members of the SSC and their children are automatically covered based on their membership. Non-member Learn to Sail participants must pay a one-time $15.00 Youth Membership fee which covers them for the duration of the program and expires August 31, 2013. Mail payment and forms to Stockton Sailing Club, 4980 Buckley Cove Way, Stockton, CA 95219 Or FAX to 209-951-5649 For Office Use Only Class Date Level Name Amount Pymnt Type 1. 2. 3. 4. 5. 2
MEDICAL CONSENT FORM Participant s Name: Age: Address: City: State: Zip Code: Date of Birth: Email: Home Phone: Mobile Phone: Parent s Name: Daytime Phone: Parent s Name: Daytime Phone: IN CASE OF AN EMERGENCY, PERSON TO CONTACT IF PARENTS OR GUARDIAN CAN NOT BE REACHED: Name: Home Phone: Relationship: Work Phone: Name: Home Phone: Relationship: Work Phone: Name: Home Phone: Relationship: Work Phone: Does your child have any pre-existing medical conditions that may prevent or hinder his/her participation in learning to sail? (For example: asthma, allergies to drugs, heart trouble, epilepsy, diabetes, physical disability etc?) Please specify. Is your child taking any medications or behavioral drugs at this time? If yes, please explain: Does your child have any allergies or reactions we should know about? (i.e. bee stings, sulfa drugs, food) Should there be any limits on your child s physical activity? If so, what are they? 3
Medical Consent Form Continued: MEDICAL INSURANCE INFORMATION Name of Insurance Company: Insurance Company Phone # Patient Record Number: Policy Number: Group Number: Ins. Co. Billing Information: Doctor: Phone: Hospital: Phone: Please list any other information of importance. If for any reason my child or I are injured I give Stockton Sailing Club personnel permission to seek treatment for my personal well-being. I have signed this document of my own free will. I do hereby authorize the performance of medical examinations and necessary treatments (including test, x-rays, drugs, etc...) as may be deemed advisable or necessary by the physician in attendance. This consent shall be in effect for the period of time that my child participates in Stockton Sailing Club Learn To Sail activities. If an emergency arises requiring a major medical procedure, the program director will attempt to reach me or a contact from the provided emergency contact list and to be guided by my wishes: but if I cannot be reached, I authorize the attending physician to act as medical judgment may dictate. Parent/Guardian signature: Parents Email: Date of Consent: Home Phone: Work Phone: Cell Phone: 4
CONTRACT, INDEMNIFICATION, RELEASE AND WAIVER The Stockton Sailing Club Learn To Sail program includes physically and emotionally demanding activities. We want to make sure you understand the risk of injury before you decide to participate. It is required that you read the following Legal Document, very carefully, make sure you understand it, fill in all the spaces, and sign it before you, or your child begin our program. No person or child will be allowed to participate without the properly filled out waiver and medical release forms. PLEASE READ THIS DOCUMENT CAREFULLY BEFORE SIGNING BELOW. THIS AGREEMENT INCLUDES A RELEASE OF CLAIMS. I am aware in signing this statement for participation in the SSC Learn To Sail Program that certain elements are physically and emotionally demanding. This program may include swimming, paddling, crawling, jumping, climbing, and other rigorous activities on the water or on the land. My child will be working with SSC Learn To Sail Instructors and with others in their group. It is possible that he/she may be injured while participating in the youth program either because of their own conduct, conduct of others in the group, conduct of SSC Learn To Sail Instructor, or the condition of the premises. Therefore, I voluntarily elect to allow my child to participate and I affirm that he/she is free of health conditions that might create undue risk to my child or others that depend on them. My child is not under a physician s care for any undisclosed condition that bears upon his/her fitness to participate. I agree to indemnify and hold harmless Stockton Sailing Club Learn To Sail Program, their agents and employees from all claims, damages, losses, injuries and expenses arising out of or resulting from participation in the youth programs. I further agree to release, acquit and covenant not to sue the Stockton Sailing Club, for all actions, causes of action claims or damages including but not limited to, claims of negligence by SSC Learn To Sail Program or 3rd party, damages in law or remedies in equity of whatever kind. I agree to the site of any lawsuit and the law governing any such lawsuit shall be California and governed by California law. As liquidated damages, I hereby agree that if the Stockton Sailing Club is forced to defend any action, lawsuit or litigation by myself, my executors, my heirs or on my families behalf, my heirs or executors and I agree to pay the Stockton Sailing Club costs and attorney fees if they successfully defend such action, lawsuit or litigation. In signing this document for my minor child I agree to pay any and all costs and attorney fees incurred by the Stockton Sailing Club in the event that the Stockton Sailing Club is forced to defend any action, lawsuit, or litigation brought by my minor child. The terms of this agreement shall continue and be in effect after the camp is over. Should any paragraph or part of this agreement be declared unenforceable by a court of competent jurisdiction the remaining paragraphs or parts shall remain in full force and effect. I authorize and release to the Stockton Sailing Club the use for any purpose of any photographic or video recorded image of the participant listed below. I have adequate health, disability and life insurance for myself, and my family. I hereby give permission for transportation to any medical facility or hospital, and I authorize for any qualified instructor or medical personnel to render necessary emergency medical care for the participant listed below. I,, of my own free will, for my family, my minor children, my heirs and executors and myself, have read, understand and acknowledge the risks and liability for myself and my family this day(s) of (month) 20. (Date above must be the first day of the class) Participant (print name) Parent/Guardian (print name) Participant Signature Date Parent/Guardian Signature Date (Parent or legal guardian must sign for all persons under 18 years of age. Proof of age may be required) 5
Sailor Questionnaire Name: Nick Name: How old are you? When is your birthday? Are you comfortable in the water? Can you swim? Where do you go to school? What are your favorite sports? What are your favorite activities or hobbies? What are your favorite foods to eat? Do you have any brothers or sisters? Have you ever been to a Stockton Sailing Club camp before? Why did you want to come to summer camp? Have you ever done any of the following activities? When? For how long? Sailing: Windsurfing: Kayaking: Canoeing: Rowing: Water Skiing: Wakeboarding: Jet Skiing: White Water Rafting: 6
What do I bring to be prepared? Swim Suit or Board Shorts Beach Towel Bottled Drinking Water Sun Block Snack Dry set of Clothes Water Shoes w/heel straps (Bare feet are not permitted) The Stockton Sailing Club will provide: PFD (Personal Flotation Device) for all participants Opti sail boat Boating Safety Instructors If participants have their own life jackets, they are more than welcome to bring them. (Please make sure personal items are labeled) Boating activities may include any of the following: Swimming, Paddling, Climbing, Classroom and Land Based Activities Note of comfort to all participants: All participants will be required to pass a swim test. Everyone is required to wear a PFD (Personal Floatation Device) at all times when on the water, in the boats or on the docks. Where is the Stockton Sailing Club? The Stockton Sailing Club is located at the West end of March Lane, across from Ladd s Marina. Take Interstate 5, exit onto March Lane, go 2 miles West on March. Buckley Cove Way will be on your left. Stockton Sailing Club Learn To Sail 4980 Buckley Cove Way Stockton, CA 95219 209-951-5600 www.stocktonsc.org 7