Build Your Sailing Skills Registration

* First Name:

* Last Name:

* Email Address

* Please select one:

AM Camp – Sailors >11 years old

PM Camp – Sailors < 11 years old

Child's First Name

Child's Last Name

Date of Birth

Child Grade

Gender

Additional Parent/Guardian First Name

Additional Parent/Guardian Last Name

Additional Parent/Guardian Cell Phone

Additional Parent/Guardian Email

Volunteer

No

Yes

Primary Emergency Contact

Primary Emergency Contact Relationship

Primary Emergency Contact Phone

Secondary Emergency Contact

Secondary Emergency Contact Relationship

Secondary Emergency Contact Phone

Medical Insurance Company

Medical Insurance Company Group #

Medical Insurance Company Policy #

Medical Insurance Policy Holder

Medical Insurance Phone Number

Physician's First and Last Name

Physician Phone Number

Hospital of Choice

Dentist's First and Last Name

Dentist's Phone Number

Does child have any allergies

No

Yes

Does child have any medical conditions

No

Yes

Does child have any disabilities

No

Yes