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2019 Bay Shore Yacht Club Sailing Application
Dave DeRuvo, Sailing Instruction Chairperson
Email address *
Sailing Application
Notes: Each class meets 3 days per week (Monday, Wednesday and Friday or Tuesday, Thursday and Friday). Emergency contacts are needed in case parents can not be reached. Swim test required - any stroke, approximately 50 yards, wearing sailing clothes, shoes, with and without a life vest. Questions?: deruvodavid@gmail.com Parent or guardian must sign a Consent and Waiver form (https://drive.google.com/file/d/1klwNvP_WPknHihejxgkXztZSujZdBLgi/view?usp=sharing).
Student - First Name *
Your answer
Student - Last Name *
Your answer
Student - Date of Birth *
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Student - Age on July 1st 2019 *
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BSYC Member? *
Home Address - Number, Street, City, State, Zip *
Your answer
Home Phone Number (NNN-NNN-NNNN) *
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Father's Name *
Your answer
Father's Phone Number(s) *
Your answer
Father's email address *
Your answer
Mother's Name *
Your answer
Mother's Phone Number(s) *
Your answer
Mother's email address *
Your answer
Local emergency contact person #1 name *
Your answer
Local emergency contact person #1 phone number(s) *
Your answer
Local emergency contact person #2 name *
Your answer
Local emergency contact person #2 phone number(s) *
Your answer
Does student have permission to leave club unaccompanied? *
How many years has student taken lessons? *
Your answer
Preferred days this summer? *
Preferred Time? *
Does the student exhibit any respiratory or heart conditions? *
Does the student exhibit diabetes or hypoglycemia? *
Does the student exhibit epilepsy? *
Does the student exhibit hemophilia? *
Does the student exhibit any allergies? If yes, please specify. *
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Does the student exhibit hearing impairment? *
Does the student exhibit any hyperactivity? *
Does the student exhibit any anxieties or fears? *
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Does the student require any medications? Please specify all medications. *
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Approximate date of students last Tetanus shot/booster? *
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Does the student have any other medical conditions? *
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Can the student complete the required swim test? Swim Test - Any stroke, approximately 50 yards, wearing sailing clothes, shoes, with and without a life vest. *
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