The New England Ice Yacht Association Inc.


2016 – 2017 Membership Application Form

October 1, 2016 – September 30, 2017

Welcome to the New England Ice Yacht Association, the leading promoter of iceboat racing and cruising events in New England.

Please complete all of the information requested below as well as the liability waiver on the second page and send (or bring to annual meeting) with a check for the appropriate amount to:

Bob Haag
NEIYA Secretary
15 Pinehurst Rd
Unionville, CT 06085

Name_______________________________________________________

Address_______________________________________________________

Email_______________________________________________________

HomeTel_____________________________________________________

Cell_______________________________________________________

BoatType______________________________________________________

SailNumber____________________________________________________

Membership Status: Returning____ New____

Annual dues for the 2015-2016 season: $30

Total enclosed: _____________________

New England Ice Yacht Association (NEIYA) Waiver

Name

address

City, State, zip code

Phone number

Emergency contact #

Sail #

Known Medical Issues

Waiver of Liability.  (Initial each line indicating that you have read the contents)

______ I acknowledge, agree and represent that I understand the Nature of Iceboating and Iceboat Racing, and cruising, ( the Activity) as sponsored by the New England Ice Yacht Association (NEIYA), and that I am qualified to participate in such activity.  I fully acknowledge that the activity takes place on frozen bodies of water in the States of Maine, New Hampshire, Vermont, Massachusetts, Rhode Island and Connecticut, that are open to the public and which may contain hazards to include open water, ice of insufficient thickness for the activity, pressure ridges, man-made or natural obstacles and motorized vehicles.  I further agree and warrant that if I believe the activity is unsafe due to ice conditions, sun glare, or other factors or hazards, I will cease participation in the activity.

______ I further understand (a) that the (activity), Iceboating and Iceboat racing, involves substantial risks and danger of serious bodily harm, including permanent disability, paralysis and death(risks) (b) these (risks) may be caused by my own activities, or inaction, the activities or inaction  of others participating in the same activity, the conditions in which the activity takes place,  or the negligence of the NEIYA, its officers and members.x

______ In consideration of the club accepting this registration application, I for myself, my heirs, next of kin, executors, administrators and assign, hereby release, absolve, and forever discharge the NEIYA, its officers, agents, sponsors, administrators, and associated  persons, from any fault, blame, warranty, responsibility or liability,  from any  death, injury, harm, misadventure, loss or damage of  equipment or personal property I suffer or sustain  or which occurs as a result of participation in any event, activity or gathering of the NEIYA.

Signature: ____________________________________
Date: ________________________________________
If under 18 must be signed by parent or Guardian