P.E.Y.C JUNIOR SAILING SCHOOL APPLICATION

Prince Edward Yacht Club, 30 Fairfield St., Picton, ON, K0K 2T0 

Student's Name: ______________________________ Date Of Birth: ____________

Parent's Name: ________________________________________________________

Mailing Address: ________________________________________________________ _____________________________________________________________________
Summer Address: _______________________________________________________ _____________________________________________________________________

Home Telephone: ___________________ Summer Telephone: _________________

P.E.Y.C. Membership Number (if applicable): _______________________________
Health Insurance Number (OHIP): ________________________________________
Name Of Health Plan (if different): ________________________________________

Allergies, Medication, or Other Considerations: _____________________________
_____________________________________________________________________
_____________________________________________________________________

C.Y.A. Level Held At Present (circle):   White I  II  III or Bronze IV  V

C.Y.A. Level Sought This Year (circle): White I  II  III or Bronze IV  V

Session Schedules: Check box
White Sail - 2 weeks sessions:  June 30 -July 11 ( ); July 14 - July 25 ( ) ; July 28 - Aug 08 ( );  Aug. 11 - Aug. 22 ( )
                   
Bronze Level - 4 week sessions: June 30 - July 25 ( );  July. 28 - Aug 22 ( )

Fees:  White Sail I, II & III (two weeks) - $325.00 + $30.00 course materials (0ne time fee)
            Bronze IV & V (four weeks) - $645.00 + $25.00 course materials

Bronze Level refundable security deposit of $250.00 covers damages due to negligence
 

Office Use Only: Registration Fee Received: $_______ Course Materials: $________

Date: D/____M/____Y/______.          By_________________________________

Parent or legal guardian please complete and sign.

I, _________________________ having registered_____________________
do hereby and forever discharge, from personal injury or loss of life, liability; and do further agree not to make claims, demands, or cause any action or claims to be made against Prince Edward Yacht Club, Prince Edward Sailing School their members, officers, directors, agents or servants for such injury or loss of life; except by reason of negligence.

Signature: __________________________  Date:______________________

Signature of Witness: ________________________________________

Note: In case of emergency, student will be taken to Prince Edward County Memorial Hospital, Picton. Phone (613) 476 - 2181

In case of emergency please notify:
Name:_____________________________     Address: _______________________________

Telephone: (      )_____________

PARENT OR GUARDIAN:  From time to time, students may have the opportunity to participate in a regatta (s) organized by a sailing school other than P.E. Sailing School.  For Bronze and Silver students these opportunities are considered to be valuable, and sometimes, an essential part of the program.  Unless we hear otherwise, in writing, it is assumed that this student has your permission to attend and participate in such events.

PLEASE INDICATE IF YOU WOULD BE WILLING TO ASSIST:
1.  Driving students to regattas (  )
2.  Chaperone at weekend regattas (  )
3.  Help organize a Picton regatta.
4.  Billet students from other sailing schools (  )
5.  Other: please specify:

Thank you for your co-operation in completing this application.  Once again we look forward to a successful season with the Prince Edward Sailing School.

Mail completed form to: Junior Sailing Program,
c/o Prince Edward Yacht Club,30 Fairfield St., Picton, ON, K0K 2T0
Attn: Sailing School Director