Date Rcvd. _____________ Fee: __________ Check # ___________ Cash___________

 

 

MID-ATLANTIC MIDGET ELIMINATIONS

7/30/2008

BHYC

Registration Fee:  ($10 you must be a member of BBYRA) Can’t turn 15 in calendar year

 

Skipper’s

Name: ____________________________________________________Birthdate:______/______/_______

 

 

Address:___________________________________________City:________________________________

 

 

State:_________________________Zip:________________US SAILING #______________________

 

 

Home Phone: (_____)_____________________Parent/Guardian:_________________________________

 

 

Crew’s

Name: ____________________________________________________Birthdate:______/______/_______

 

 

Address:___________________________________________City:________________________________

 

 

State:_________________________Zip:_________________US SAILING #______________________

 

 

Home Phone: (_____)_____________________Parent/Guardian:_________________________________

 

 

Boat Type: (circle one)     SINGLE-HANDED                                              DOUBLE-HANDED

 

Sail Number:__________________________________________________________________________

 

Yacht Club: ________________________________________________________________

 

Registrations by mail due by July 27th to

Jim Walsh

25 Wayside Dr.

Brick, NJ 08724

732-295-1872

E-Mail:

On-site registration also will be available

 

You must complete both pages of this form

 

Mid-Atlantic Midget MEDICAL RELEASE

Skipper’s

Name: ____________________________________________________Birthdate:______/______/_______

 

Address:___________________________________________City:________________________________

 

State:_________________________Zip:________________________USSA #______________________

 

Home Phone: (_____)_____________________Parent/Guardian:_________________________________

 

Physician:________________________________________Physician’s Phone: (_____)_______________

 

 

Insurance Company ________________________________Policy Number: ________________________

 

 

Crew’s

Name: ____________________________________________________Birthdate:______/______/_______

 

 

Address:___________________________________________City:________________________________

 

 

State:_________________________Zip:________________________USSA #______________________

 

 

Home Phone: (_____)_____________________Parent/Guardian:_________________________________

 

Physician:________________________________________Physician’s Phone: (_____)_______________

 

Insurance Company ________________________________Policy Number: ________________________

 

We agree to abide by the rules of the Ocean Gate Yacht Club, its Junior Sailing committee, the host town, the BBYRA and the Mid-Atlantic Midgets.  We understand that failure to comply may result in elimination from this event.  We understand that sailing involves risk of personal injury and/or property damage.  It is understood that effort shall be made to contact the undersigned prior to rendering emergency treatment to the patient, but that emergency treatment shall not be withheld if the undersigned cannot be reached. We hereby release any claims which we may have against the host club, its members, officers, employees and event personnel from any liability for personal injury and property damage which we may suffer during or arising out of participation in this event.    

 

Date:_________

Skipper’s Signature:________________________________________________________________________

 

Skipper’s Parent/Guardian Signature:_________________________________________________

 

Emergency Contact Name: _____________________________________Phone (_____)__________________

 

Emergency Contact Name #2:___________________________________Phone (_____)__________________

 

 

Date:_________

Crew’ss Signature:________________________________________________________________________

 

Crew’s Parent/Guardian Signature:_________________________________________________

 

Emergency Contact Name: _____________________________________Phone (_____)__________________

 

Emergency Contact Name #2:___________________________________Phone (_____)__________________