CYC Adult Sailing Program Registration
Program registration for adult sailing programming.
Email address *
Sailor's Name *
Your answer
Gender *
Sailors Birth Date *
MM
/
DD
/
YYYY
Program you are registering for *
Additional Registration (if registering for multiple programs)
Member/ Non-Member *
If Member please provide member number
Your answer
Address *
Your answer
Phone: Cell *
Your answer
Phone: Home
Your answer
Medical Information
Please list any allergies, medical conditions including those requiring maintenance medications (Diabetes, Asthma, Seizures etc)
Medical Information
Your answer
Emergency Contact Information
Please provide details below
Emergency Contact Name *
Your answer
Emergency Contact Number *
Your answer
Emergency Contact Relation to student *
Your answer
Insurance Information
Please provide us with insurance information below
Insurance carrier *
Your answer
Policy Number *
Your answer
Name of Policy Holder *
Your answer
Policy Holder's Contact Number (if different from above)
Your answer
Billing Information
Please provide how you would like to be billed for this program- please note if you are a non-member payment needs to be procured before your sailors first day of programming. If you choose to use a CC please note that a staff member will contact you for the card details.
Payment Method *
A copy of your responses will be emailed to the address you provided.
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