2024 BYC Adult Learn to Sail Program Application
Thank you for your interest in the BYC Adult Learn to Sail Program!  

Classes meet on 6 Monday evenings  from 1700 - 2000 hours. June 24, July 1, 8, 15, 22, 29

The cost of the course is $325.  
Payment will be due once you have received confirmation of enrollment in the class
Email *
It is essential that you attend all 6 sessions (absences due to illness are excused).  If you know that you are not able to attends all 6 classes please indicate the dates you will miss.  Priority will be given to registrants who are able to be there for all 6 sessions. *
Required
First Name *
Last Name *
Street Address (summer) *
Town *
State *
Zip Code *
If your mailing address is different from above, please enter it here.
Home Phone # *
Cell Phone # *
E-mail address *
Previous sailing experience (Check all that apply to you) *
Required
Please describe your previous sailing experience
Emergency Contact (Name and phone where they can be reached during class hours): *
List any medical factors that would be pertinent in emergency treatment, i.e. allergies, blood type, history of seizures, and any current medication.   *
Do you have a history of, or do you currently have, any physical conditions that we should know about or that might limit you in fully participating in this course?   *
Required
If yes, please explain:
Are you able to swim 50 yards without stopping? *
Primary Care Physician's Name & Phone Number *
Health Insurance Provider's Company Name & Phone Number *
Health Insurance Information: Policy # *
Policy Holder's Name *
Once you have received confirmation that you are enrolled you will be billed for the sessions after registrations for the course have closed (June 1).                                          Please write your Member Number for Billing               OR Write "Non-member" . *
Permission to Provide Necessary Treatment of Emergency Care:  I hereby give permission to the medical personnel selected by the program director to order x-rays, routine tests, or treatment; to release any records necessary for insurance purposes; and to provide or arrange necessary related transportation for me.  If I am unable to communicate and my emergency contact cannot be reached in an emergency, I hereby give permission to the physician selected by the program director to secure and administer treatment, including hospitalization, for me.Emergency Care:I hereby give permission to the medical personnel selected by the program director to order x-rays, routine tests, or treatment; to release any records necessary for insurance purposes; and to provide or arrange necessary related transportation for me.  If I am unable to communicate and my emergency contact cannot be reached in an emergency, I hereby give permission to the physician selected by the program director to secure and administer treatment, including hospitalization, for me. *
Required
Additional Questions or Comments? Please write them in here!
Thank you for your interest in the BYC Adult Sailing course!  A confirmation that your form has been submitted will be sent immediately following the completion of this form.  We are currently full and starting a waiting list.  You will receive an email with status updates as they become available. We will try to get as many epopel into the course as possible. Thanks again for your interest!
A copy of your responses will be emailed to the address you provided.
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