Dynamic Form - Indian Harbor Yacht Club

Contact Information

* Sailor's First Name:

* Sailor's Last Name:

* Age At Start Of Session:

* Parent/Guardian Name:

Member Number:

* Address:

* City:

* State:

* Zip:

* Primary Phone:

Secondary Phone:

* Parent/Guardian's Email:

Other Email:

* Emergency Notification (other than parent):

* Phone Number:

* T-Shirt Size:

* JSA MEMBER:

Yes

No

Program Registration

Fall Feva Training

GCDS

Medical Information

* Physician Name:

* Phone Number:

* Are You Currently Taking Any Medications?

Yes

No

If yes, which medications and for what reason?

* Do You Have Any Allergies?

Yes

No

If yes, please explain allergies:

* Has a Doctor Placed Any Restrictions On Your Activity?

Yes

No

If yes, please explain restrictions:

Indian Harbor Yacht Club Agreement, Waiver, and Release

* "Parents"

* "Minor"

* Address:

Consent to Participation

Parents acknowledge, consent, and grant permission for Minor to participate in the 2017 Junior Sailing Program at Indian Harbor Yacht Club (“IHYC”).

The sport of sailing and participation in the Program present certain inherent risks of physical harm as well as property loss. On behalf of Minor, Parents acknowledge, accept and assume these risks and confirm that Minor is participatingin the Program voluntarily and at his/her own risk.

Parents acknowledge, consent, and grant permission for Minor to use and enjoy property and facilities offered in connection with IHYC and to participate in activities including, but not limited to, travel to other states, boating, sailing, sailing lessons, sailboat racing, and other water-related sports or activities in the State of Connecticut or elsewhere.

Parents further acknowledge, consent, and grant permission for IHYC, its employees and agents to have the right to take photographs, videotape, or digital recordings of Minor and to use these in any and all media, now and hereafter known, exclusively for the purpose of IHYC publications, without financial remuneration. Parents affirm that they have the authority to act as stated in this Waiver and Release.

Release

In consideration of participating in the activities at IHYC, Parents, for themselves and for Minor as his/her legal representatives, heirs and assigns hereby release, waive, and discharge IHYC, its officers, members, owners, managers, agents, employees, and representatives, from all liability for any and all loss or damage, and any claim for damages resulting from Minor's participation in the IHYC program, or accidental injury, to Minor's person or property including injury resulting in death.

Parents waive any and all rights to claims for IHYC's negligence resulting in bodily injury, death, or property damage while the Minor is in or upon the property of IHYC, or while participating in any IHYC activity in the State of Connecticut or elsewhere.

Parents agree to indemnify and hold harmless IHYC, and its officers, members, owners, managers, agents, employees, and representatives, from any loss, liability, damage, or cost IHYC may incur as a result of Minor's activities while participating in IHYC activities.

Parents acknowledge that Minor is in the care of IHYC while Minor participates in IHYC activities, either in the State of Connecticut or elsewhere. Parents hereby authorize and consent that IHYC, and any of its officers, members, and/or employees, may seek and provide any and all medical care and attention on behalf of Minor should injury, regardless of the extent, occur to Minor, and further authorize all physicians, hospitals, and other licensed medical providers to administer all required medical care and treatment to and for Minor, without further notice or written authorization. It is understood by and between IHYC and Parents that reasonable efforts will be made to contact and inform Parents of any injury, but that such contact, whether successful or not, shall not prevent the administering of any necessary medical attention and treatment as consented to herein. Parents acknowledge that they will remain responsible for the costs of all such medical treatment including transport by ambulance, and agree to indemnify and hold harmless IHYC from any such costs.

Parents acknowledge that the boats and/or other property of IHYC and others will be used by participants in the IHYC program and are subject to normal wear and tear. Parents hereby agree to be responsible and pay for any property damage, beyond normal wear and tear, as defined by IHYC, to the boats and/or other property of IHYC and others used by Minor as a participant at IHYC.

Parents expressly agree that this Waiver and Release shall be governed by and construed in accordance with the laws of the State of Connecticut, that it is intended to be broad and as inclusive as permitted by the laws of the State of Connecticut, and that if any portion of it is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.

Parents acknowledge that they understand and have been fully informed of the contents of this Waiver and Release by reading it before signing below.

In witness whereof, Parents have executed this Waiver and Release the day and year written below.

* Electronic Signature of Parent or Guardian

* Date

* Denotes Required Field