2014 Junior Sweepstakes Regatta
Entry Form
(Note: an Entry Form and Fee are required for each participant, whether skipper or crew)
Participant’s Name: __________________________________ Age as of 8/4/14: _____
Address: _________________________________________________________________
Phone Number: _______________ T-Shirt Size requested*: YL S M L XL
*T-Shirts will be reserved based on date registration is received. T-Shirts for late registrations are subject to availability.
Circle Club: FHSC (River Rats) KYC MBC RYC SSYC AHSEP Other: ________________
Circle Boat Type:
Laser Radial Club 420
Optimist: Green White Blue Red
Skipper’s Name: ___________________________________
Club 420: Crew’s Name: ___________________________________
(Note: For C-420’s both Skipper and Crew must register, submit medical / liability form and pay fee)
*Sail Number: ______________ (IMPORTANT for scoring - get from instructor if using a club boat)
Entry Fees: South Shrewsbury Regatta $55 * _____________
(SSYC – Mon & Tues)
North Shrewsbury Regatta $55 * _____________
(MBC – Wed & Thurs)
Both Rivers Regatta $85 * _____________
(SSYC – Mon & Tues, MBC – Wed & Thurs)
*Late Registration after August 2
(subject to availability) _____________
($65 per river or $95 for both rivers)
Total: _____________
Total Paid: __________ Check ___________ Cash __________
Please make checks payable to “Junior Sweepstakes Regatta”
Entry forms and payment must be returned to a representative of your club’s Jr. Program by August 1st.
Entry forms turned in after August 1 are subject to the late registration fee of $10 per river.
Please Register Early to Help Us Plan and Make this Regatta a Success!!!
Date Received: ___________
*(Instructors: Please provide sail numbers on this Entry form to expedite registration at the regattas.)
WAIVER ON REVERSE SIDE MUST BE COMPLETED.
LIABILITY WAIVER, RELEASE AND EMERGENCY TREATMENT AUTHORIZATION
I confirm that I am the Parent or Guardian of the Participant listed on the reverse side of this Waiver and Release. I understand that sailing involves the risk of personal injury and property damage. In consideration of the Participant being allowed to participate in the Junior Sweepstakes Regatta, I agree to waive and release the Junior Sweepstakes Regatta, the Fair Haven Sailing Club (River Rats), the Keyport Yacht Club, the Monmouth Boat Club, the Rumson Yacht Club, the Shrewsbury Sailing and Yacht Club, The Atlantic Highlands Sail Education Program and each of their members, instructors, volunteers, officers, directors, trustees and employees (all jointly and severally referred to as the “Sponsors”) from any and all liability and claims arising out of the Participant’s attendance and participation in the Junior Sweepstakes Regatta. I further agree to defend, indemnify and hold harmless the Sponsors from any and all claims, demands, expenses and liability, whether for personal injury, death, property damage or otherwise, which is caused by the Participant or which in any way relates to or arises out of his/her participation in the Junior Sweepstakes Regatta.
I authorize the Sponsors to sanction emergency treatment for the Participant in the event that none of the people listed below can be contacted at the time of an emergency.
Child’s Name:____________________________________________
Parent or Guardian Signature:
Print Name:
Date:
Emergency Contacts:
Name: Relationship Day & Evening Telephone, Cell Phone, Beeper
Please list any medical information for the Participant that emergency treatment providers should know, including any current medications, allergies or medical conditions:
Allergies:
Current Medications:
Medical Ailments or Conditions:
Doctor’s Name and Phone Number:
Health Insurer:
Policy Number:
Other:
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